Saturday, February 29, 2020

PECOS - contact details and FAQ

PECOS TECHNICAL ASSISTANCE
CONTACT INFORMATION

ICN 903766 January 2019
PRINT-FRIENDLY VERSION

Target Audience: Medicare Fee-For-Service Providers

The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink. You may encounter problems that require technical support when using the Provider Enrollment, Chain, and Ownership System (PECOS). Knowing which Centers for Medicare & Medicaid Services (CMS) contractor to contact is the first step toward a solution. This fact sheet describes common problems and tells you who can best resolve them.

COMMON PROBLEMS AND WHOM TO CONTACT

Problem: Navigating or Accessing PECOS Website

When you experience: system-generated error messages, trouble navigating through PECOS screens, issues accessing PECOS, printing problems, or you have a valid Identity & Access Management (I&A) System user ID and password but cannot access PECOS because of a malfunction (for example, the website operates slowly or not at all, or a system-generated error message prevents data entry).

NOTE: A system-generated error message does not include messages created when you enter data incorrectly or ignore system prompts.

Solution: Contact CMS EUS Help Desk Find information on common problems, ask a question, or look up previous support history on the External User Services (EUS) website.

Phone: 866-484-8049 (TTY 866-523-4759)

Email: EUSSupport@cgi.com

Live Chat: Go to the EUS website screen, on the right side choose “Live Chat.” EUS Hours of Operation: Monday–Friday, 6 am–6 pm CT; Saturday–Sunday, closed


Problem: Accessing the PECOS System Before you log in to PECOS, you need a valid I&A System user ID and password.

NOTE: Passwords expire every 60 days. You cannot log in to the I&A System (and PECOS) until you reset your password. The I&A System tells you the number of days until your password expires. Go to the “My Profile” tab and see the password section. If you attempt to log in to PECOS with an expired password, you will be redirected to the I&A System to reset your password. Solution: Access I&A System or Contact I&A System Help

The I&A System website allows you to create an I&A System user ID and password, change your password, and recover forgotten login information. Additionally, you can access several resources:

** I&A Frequently Asked Questions (FAQs) helps you resolve common I&A System problems

** I&A System Quick Reference Guide provides step-by-step instructions, including screenshots, about I&A System features and tools

HINT: On the I&A System website, choose the “Help” button in the upper right corner of any webpage for more information on the topic of that webpage.

Problem: Enrolling in Medicare via PECOS (Non-Technical) While using PECOS, you have a question about provider enrollment or you experience problems enrolling and need guidance on completing specific sections of the PECOS enrollment application.

Solution: Read Provider Enrollment Publications or Contact Your Medicare Enrollment Contractor Browse the Medicare Learning Network® (MLN) listing of Medicare Provider-Supplier Enrollment National Educational Products. These publications focus on provider-specific Medicare enrollment and Medicare enrollment via PECOS. Refer to the Medicare Provider Enrollment Contact List to find detailed contact information on enrollment, or if you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.


I had an existing account I used to log in to PECOS and/or the EHR Incentive Program; can I still use it?

Yes, you can use your previous NPPES or PECOS User ID and password to login. All existing accounts used to access PECOS and EHR Incentive Program have been converted. NPPES User IDs used by Individual Providers to access all systems have also been converted.

Note that if your account has been used within the last 365 days but not in the last 180 days, you will need to reset your password. If your account has not been used in the last 365 days, you will need to re-verify your information and you will have to create a new User ID. If you are not sure if you have an account, you can check by using the forgot User ID or Password link on the I&A, PECOS, or NPPES homepage.

What do I do if my account becomes disabled?

If your account has been used within the last 365 days but not in the last 180 days, it will become disabled. When you login, the system will check your account status, and, if it is disabled, you will be required to reset your password. The system will automatically navigate you to the page to reset your password.

Why am I being told to register again if I already have an account?

If you have not accessed your account for 365 days or more, you will be required to create a new User ID to re-confirm your information. If you were previously registered as an Authorized Official or Delegated Official with your employer(s), you will need to add your employer(s) again. If you are a Staff End User, you will need to contact your employer's Authorized Official or Delegated Official to re-invite you. Important Note: Any previous connections between your employer(s) and others have been maintained in the system and will be visible after you are re-approved.

What do I do if I cannot remember my User ID?

If you cannot remember your User ID, you may select the “Retrieve Forgotten User ID” link on the I&A Sign In page and follow the instructions on the screen. You must provide either a unique email address associated with your account to receive your User ID via e mail, or enter the required User Information associated with your account to view your User ID immediately.

Note: If you retrieve your User ID without using your e-mail, you will also be required to change your password.

When did the I&A changes go into effect** October 7, 2013.

I had an existing account I used to log in to PECOS and/or the EHR Incentive Program; can I still use it?


Yes, you can use your previous NPPES or PECOS User ID and password to login. All existing accounts used to access PECOS and EHR Incentive Program have been converted. NPPES User IDs used by Individual Providers to access all systems have also been converted.

Note that if your account has been used within the last 365 days but not in the last 180 days, you will need to reset your password. If your account has not been used in the last 365 days, you will need to re-verify your information and you will have to create a new User ID. If you are not sure if you have an account, you can check by using the forgot User ID or Password link on the I&A, PECOS, or NPPES homepage.

What do I do if my account becomes disabled?

If your account has been used within the last 365 days but not in the last 180 days, it will become disabled. When you login, the system will check your account status, and, if it is disabled, you will be required to reset your password. The system will automatically navigate you to the page to reset your password.

Why am I being told to register again if I already have an account?

If you have not accessed your account for 365 days or more, you will be required to create a new User ID to re-confirm your information. If you were previously registered as an Authorized Official or Delegated Official with your employer(s), you will need to add your employer(s) again. If you are a Staff End User, you will need to contact your employer's Authorized Official or Delegated Official to re-invite you. Important Note: Any previous connections between your employer(s) and others have been maintained in the system and will be visible after you are re-approved.

What do I do if I cannot remember my User ID?

If you cannot remember your User ID, you may select the “Retrieve Forgotten User ID” link on the I&A Sign In page and follow the instructions on the screen. You must provide either a unique email address associated with your account to receive your User ID via e mail, or enter the required User Information associated with your account to view your User ID immediately. Note: If you retrieve your User ID without using your e-mail, you will also be required to change your password.

How often will I have to reset my password?

Passwords expire every 60 days. Note: there is a password section on the My Profile tab which will tell you how many days until your password expires. For example, Your Password will expire in 37 day(s).

Reminder: An expired password simply means that you cannot log in to the I&A, Electronic Health Record (EHR) Incentive Programs or the Provider Enrollment Chain and Ownership System (PECOS) until you reset your password. An expired password will not affect your NPI, Medicare enrollment, claims payments, or EHR incentive payments; and will not remove the ability for any Surrogates to attest or work on behalf of their providers if they had previously been authorized in the system. It will only prevent logging in to those systems until the password is reset. Password Reset Requirements in the Identify & Access (I&A) Management System Passwords in the I&A system, which control access to the following systems: NPPES, PECOS, and Electronic Health Record (EHR) Incentive Programs, will expire every 60 days.

Important Note: If your password expires it will NOT impact your NPI, Medicare enrollment, claims payments, or EHR incentive payments; and will NOT remove the ability for any Surrogates to attest or work on behalf of their providers if they had previously been authorized in the system. It will only prevent logging in to those systems.

In the event that your password does expire you will be prompted to reset your password the next time you attempt to login to any of the systems. You may monitor how long until your password expires by viewing the password section on the My Profile tab within I&A, which will tell you how many days until your password expires.

How does I&A work with other systems (PECOS, EHR, NPPES)?


I&A allows you to create one account to access NPPES, PECOS, and EHR Incentive Program. I&A allows Authorized Officials and Delegated Officials to:

1) Manage Staff: The ability to add staff, modify roles and provider access for existing staff associated with your employer.

2) Manage Connections: The ability to create, approve, reject, and disable connections between your employer and other Organizations (both Provider and Non-Provider organizations).

I have an NPPES account for an NPI; can I use it in I&A** Yes, if you are an Individual Provider with an NPPES account for your NPI, you can login to I&A using your NPPES User ID and password. You may also use this account to log in to PECOS and EHR Incentive Program. Note: You may need to update some account information in I&A. NPPES User IDs used to access organization NPIs (Type 2 NPIs) cannot be used in I&A and will become obsolete. You will need to create an account in I&A in order to access PECOS and EHR

Monday, December 16, 2019

CPT 0030U, G9143 - Genotype-Guided Warfarin Dosing

Code Description CPT

0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) (new code effective 1/1/18)


G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)


Genotype-Guided Warfarin Dosing


Introduction

Warfarin (Coumadin) is a blood thinner that works by reducing the blood’s ability to clot. It’s often prescribed to prevent blood clot formation in people who have conditions like atrial fibrillation. Finding the correct dose can be complicated. Too high a dose can cause bleeding. Too low a dose can result in blood clots being formed. Factors such as age, weight, use of other medications, and smoking go into the calculation of how much is prescribed. Once the drug is prescribed, the doctor then adjusts the dose based on blood tests. Two genes have been associated with how well the body processes warfarin. Genetic tests have been developed to look at these genes to try to determine warfarin dosing. These genetic tests are investigational (unproven). Medical studies do not show whether genetic testing to try to adjust warfarin doses leads to better health results. More studies are needed.

Note:   The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Test Investigational 


Testing of cytochrome p450 2C9 (CYP2C9), P450 4F2 (CYP4F2), and vitamin K epoxide reductase subunit C1 (VKORC1)

Coding Genotyping for CYP2C9, CYP4F2, and VKORC1 variants is considered investigational to manage the administration and dosing of warfarin, including: * Guiding the initial  warfarin dose  * Decreasing the time needed to achieve a stable international  normalized ratio (INR) * Reducing the risk of serious bleeding

Related Information 

Genetics Nomenclature Update

The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics (see  Table 1). The Society’s nomenclature is recommended by the Human Variome Project, the HUman Genome Organization, and by the Human Genome Variation Society itself.  The American College of Medical Genetics and Genomics and the Association for Molecular Pathology standards and guidelines for interpretation of sequence variants  represent expert opinion from both organizations, in addition to the College of American Pathologists. These  recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table 2 shows the  recommended standard terminology*“pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign”*to describe variants identified that cause  Mendelian disorders.

Table 1. Nomenclature to Report on Variants Found in DNA
Previous  Updated  Definition

Mutation Disease-associated variant

Disease-associated change in the DNA sequence
Variant Change in the DNA sequence 
Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives
Table 2. ACMG-AMP Standards and Guidelines for Variant Classification
Variant Classification Definition
Pathogenic Disease-causing change in the DNA sequence
Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology.

Genetic Counseling


Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing; further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Wednesday, November 13, 2019

CPT 81225, 81226, 81227 - Genotype-Guided Tamoxifen Treatment

Code Description CPT

81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) 

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) 

81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) 

81479 Unlisted molecular pathology procedure

81599 Unlisted multianalyte assay with algorithmic analysis



Genotype-Guided Tamoxifen Treatment

Introduction


Certain types of breast cancer are affected by hormones. Cancer cells that are said to be estrogen receptor positive (ER-positive) have receptors that attach to estrogen. Once attached, estrogen then acts like a fertilizer to help the cancer grow. Hormone therapy is used to prevent estrogen from connecting to the receptors. Tamoxifen is a type of hormone therapy that can be used for ER-positive breast cancer to prevent it from coming back and to treat breast cancer that’s already spread to other parts of the body. It’s also used for ER-positive ductal carcinoma in situ (DCIS). To process tamoxifen into its more active form, the body uses a specific, important enzyme (CYP2D6) that’s made by a particular gene. A small percentage of people (about 10%) have a form of the gene that doesn’t make as much of this important enzyme as most other people make. A genetic test has been developed to try to see if a person has the gene form that makes a smaller amount of the needed enzyme. This genetic test is investigational (unproven). Large, well-designed medical studies don’t show a strong link between this gene and tamoxifen’s effectiveness. More studies are needed. 

Note:  The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.


Policy Coverage Criteria  Test Investigational  Cytochrome P450 2D6 (CYP2D6) testing 

Coding 


Genotyping to determine cytochrome P450 2D6 (CYP2D6) variants is considered investigational for the purpose of managing treatment with tamoxifen for women at high risk for or with breast cancer.



Related Information 

Genetics Nomenclature Update


The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics. It is being implemented for genetic testing medical evidence review updates starting in 2017 (see Table 1).


The Society’s nomenclature is recommended by the Human Variome Project, the HUman Genome Organization, and by the Human Genome Variation Society itself.

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

Table 1. Nomenclature to Report on Variants Found in DNA 

Previous  Updated  Definition
Mutation Disease-associated variant
Disease-associated change in the DNA sequence
Variant Change in the DNA sequence 
Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives

Table 2. ACMG-AMP Standards and Guidelines for Variant Classification
Variant Classification Definition
Pathogenic Disease-causing change in the DNA sequence
Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology. 


Description

Tamoxifen is prescribed as a component of adjuvant endocrine therapy to prevent endocrine receptor-positive breast cancer recurrence, to treat metastatic breast cancer, and to prevent disease in high-risk populations and in women with ductal carcinoma in situ. Tamoxifen is a prodrug that undergoes extensive metabolism to yield its active form: 4-hydroxy tamoxifen and endoxifen (primary active form) via the CYP2D6 enzyme. Variants in the CYP2D6 gene are associated with significant alterations in endoxifen concentrations leading to the hypothesis that CYP2D6 variation may affect the clinical outcomes of women treated with tamoxifen but not with drugs not metabolized by CYP2D6, such as anastrozole. Gene Expression-Based Assays for Cancers of Unknown Primary

Thursday, October 17, 2019

CPT 81504, 81540, 81599 - Oncology (tissue of origin)

Coding    Code Description CPT

81479 Unlisted molecular pathology procedure

81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores

81540 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype

81599 Unlisted multianalyte assay with algorithmic analysis


Introduction

A primary site is the part of the body where cancer started. Cancers are named on this primary site, even when they spread to other parts of the body. For example, if cancer starts in the breast but spreads to the bones, lungs, or liver, it is still classified as breast cancer. Cancer treatment is often based on the primary cancer. In rare cases, a cancer may have already spread before the original cancer is found. This is known as cancer of unknown primary. Cancers of unknown primary happen in three to four percent of all cancers in the United States. Certain genetic tests are being studied as one way to try to find the original site of the cancer. There is not yet enough scientific evidence about how these genetic tests might affect overall health outcomes. These tests are considered unproven (investigational).


Policy Coverage Criteria 

Type of Test Investigational


Gene expression profiling Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor.

Related Information 

Genetics Nomenclature Update


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


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

Table 1. Nomenclature to Report on Variants Found in DNA
Previous  Updated  Definition
Mutation Disease-associated variant Disease-associated change in the DNA sequence
 Variant Change in the DNA sequence 

Familial variant Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives
Table 2. ACMG-AMP Standards and Guidelines for Variant Classification
Variant Classification  Definition
Pathogenic Disease-causing change in the DNA sequence
Likely pathogenic Likely disease-causing change in the DNA sequence 
Variant of uncertain significance Change in DNA sequence with uncertain effects on disease
Likely benign Likely benign change in the DNA sequence
Benign Benign change in the DNA sequence
American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology

Genetic Counseling

Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of  genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing,  including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the  utilization of genetic testing substantially and may reduce  inappropriate testing; further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Evidence Review 

Description


Cancers of unknown primary represent 3% to 4% of cancers diagnosed in the United States. These cancers are heterogeneous and many accompanied by poor prognoses. A detailed history and physical combined with imaging and tissue pathology can identify some, but not all, primary sources of secondary tumors. It is suggested that identifying the likely primary source with gene expression profiling to direct treatment may improve health outcomes.

Background

Cancers of Unknown Primary

Cancers of unknown primary (CUPs), or occult primary malignancies, are tumors that have metastasized from an unknown primary source; they make up about 3% to 4% of all cancers in the United States. Identifying the primary origin of a tumor can dictate cancer-specific treatment, expected outcome, and prognosis.

Most CUPs are adenocarcinomas or undifferentiated tumors; less commonly, they may be squamous carcinomas, melanoma, soft tissue sarcoma, or neuroendocrine tumors. Osteo- and chondrosarcomas rarely produce CUPs. The most common primary sites of CUPs are the lung and pancreas, followed by colon and stomach, then breast, ovary, prostate, and solid-organ carcinomas of the kidney, thyroid, and liver. Conventional methods used to aid in the identification of the origin of a CUP include a thorough history and physical examination; computed tomography scans of the chest, abdomen, and pelvis; routine laboratory studies; and targeted evaluation of specific signs and symptoms.

Diagnosis and Classification


Biopsy of a CUP with detailed pathology evaluation may include immunohistochemical (IHC) analysis of the tumor. IHC analysis identifies different antigens present in different types of tumors and can usually distinguish an epithelial tumor (ie, carcinoma) from melanoma or sarcoma. Detailed cytokeratin panels often allow further classification of carcinoma; however, tumors of different origins may show overlapping cytokeratin expression. Results of IHC may provide a narrow differential of possible sources of a tumor’s origin, but not necessarily a definitive answer.
Recent advances in the understanding of gene expression in normal and malignant cells have led researchers to explore molecular classification to improve the identification of the site of origin of a CUP. The molecular classification of cancers is based on the premise that, despite different degrees of differentiation, tumors retain sufficient gene expression “signatures” as to their cell of origin, even after metastasis. Theoretically, it is possible to build a gene expression database spanning many different tumor types to compare to the expression profile of very poorly differentiated tumors, or a CUP, to aid in the identification of the tumor type and organ of origin. The feasibility of using molecular classification schemes with gene expression profiling (GEP) to classify these tumors of uncertain origin has been demonstrated in several studies.

Tissue of Origin Testing, Treatment Selection, and Health Outcomes 


Patients with CUP have generally poor prognoses. For example, patients with disease limited to lymph nodes have a median survival of 6 to 9 months, and those with a disease that is extranodal 2 to 4 months.

The premise of tissue of origin testing in CUPs is that identifying a likely primary tumor site will inform treatment selection leading to improved survival and other outcomes or as a predictive test. To evaluate whether treatment selection can be improved, the ability of a test to suggest a likely site of origin (clinical validity) must be first be shown. But demonstrating clinical validity may be problematic because patients with CUPs have no identified primary tumor for a reference standard.
Imperfect reference standards must be relied on such as the available presumptive or a reference pathologic diagnosis, known tumor types, or comparisons IHC. A primary tumor diagnosed during follow-up might also be used as a reference standard, but its use would be subject to potential selection bias. Therefore, even substantial evidence supporting the ability of a test to suggest a likely site of origin will be insufficient to infer benefit. Convincing evidence for benefit requires demonstrating that using a test to select treatment will improve outcomes. 


The Tissue of Origin test (formerly known as the PathWork Tissue of Origin Test and ResponseDX: Tissue of Origin; Cancer Genetics) measures the expression of 2000 genes and compares the similarity of the GEP of a CUP to a database of known profiles from 15 tissues with more than 60 histologic morphologies. The report generated for each tumor comprises a “similarity score,” which is a measure of similarity of GEP of the specimen to the profile of the 15 known tumors in the database. Scores range from 0 (very low similarity) to 100 (very high similarity), and sum to 100 across all 15 tissues on the panel. If a single similarity score is 30 or more, it indicates that this is likely the tissue of origin. If every similarity score is between 5 and 30, the test result is considered indeterminate, and a similarity score of less than 5 rules out that tissue type as the likely origin. PathWork Diagnostics developed the test, but the company filed for bankruptcy in early 2013; Response Genetics purchased its assets, and it, in turn, was acquired by Cancer Genetics in late 2015.
An alternative method to measure gene expression is real-time quantitative polymerase chain reaction (RT-qPCR). RT-qPCR can be used at the practice level; however, it can only measure, at most, a few hundred genes, limiting tumor categorization to 7 or fewer types. Tumor classification accuracy rates using real-time polymerase chain reaction have been reported to be as high as 87%, but lower (71%) for more undifferentiated tumors.

 One assay that uses RT- qPCR is the CancerTYPE ID (Biotheranostics) assay, which measures the expression of messenger RNA in a CUP tissue sample. Samples for this are ormalin-fixed,  paraffin-embedded (FFPE) tissue sections or unstained 10 micron sections on glass slides. Expression levels of 92 genes (87 tumor-associated genes and 5 reference  genes for normalization) are used to detect 27 tumor types in a known database of 578 tumors with a range of 5 to 49 tumors per type. The report generated is the  probability for the main cancer type, possible subtypes, tumor types not able to be excluded, and those ruled out with 95% confidence calculated by K nearest neighbor  analysis.

Wednesday, September 25, 2019

CPT T1016, T1017 - Targeted case Managment services

CPT Code Definition

T1016 Case management, each 15 minutes
T1017 Targeted case management, each 15 minutes


DESCRIPTION OF SERVICES

Targeted case management (TCM) programs are available to assist participants with gaining access to the full range of available mental health services, as well as to any needed medical, social, financial, counseling, educational, housing, and other supportive services needed in order to maintain stability in the community.  TCM is available to adults, as well as children and adolescents. Each population must meet the state of Maryland’s medical necessity criteria for TCM services. Adult TCM services offer two levels of service intensity depending on the needs of the participant.

TCM providers will need to clearly articulate the requested intensity of services and rationale when entering authorization requests in ProviderConnect. Child and adolescent TCM (also known as care coordination services) providers have three levels of intensity to select depending on the needs of the participant. Child and adolescent TCM providers need to clearly articulate the requested intensity and rationale when entering authorization requests in Provider Connect.

SERVICE RULES

The TCM service provider is expected to exchange information and coordinate care with the participant’s PCP and other treatment (i.e. substance use disorder treatment, therapist, psychiatrist, etc.) providers when clinically appropriate and with consent when required.   One unit of TCM service for an adult is any service provided on any given date of service where the contact is a minimum of one hour of either face-to-face contact with the participant or contacts with stakeholders and service providers on behalf of the participant. The level of TCM services is based on the severity of the participant's mental illness (Please see Section 7.21 for more information). 


**Adult Level I (Adult General) TCM has a maximum of two units of service per month.  

**Adult Level II (Adult Intensive) TCM has a maximum of five units of service per month.  

One unit of service for a child or adolescent TCM is any service provided on any given date of service where the contact is a minimum of 15 minutes of face-to-face contact with the participant, the minor’s parent/guardian, or contacts with stakeholders and service providers on behalf of the participant. The level of TCM services is based on the severity of the participant's mental illness (Please see Section 7.20 for more information).

**Child and adolescent, Level I (General) TCM has maximum of 12 units of service per month.  A minimum of two units of face-to-face contacts with the participant are required. 

**Child and adolescent Level II (Moderate) TCM services have a maximum of 30 units per month and a minimum of four units of face-to-face contact with the participant. 

**Child and adolescent Level III (Intensive) TCM services have a maximum of 60 units per month. A minimum of six units of face-to-face contact with the participant are required.

For child and adolescent Level I and Level II TCM services, four additional units of service above and beyond the monthly maximum may be billed during the first month of service to the participant and every six months thereafter to allow for comprehensive assessment and reassessment of the participant.

A unit of service for telephonic contact for a child and adolescent TCM participant may not be reimbursed unless the provider has delivered at least eight minutes of service.



REIMBURSEMENT POLICY Mental Health-Targeted Case Management Services


Mental  Health-Targeted Case Management  (MH-TCM) services help adults with a serious and persistent mental  illness (SPMI) and children with a severe emotional disturbance (SED) gain access to needed medical, social, educational, vocational, financial and other necessary services as they relate to the recipient’s   mental  health needs. Coverage is a health plan responsi  bility  for Blue Plus® Minnesota Health Care Program (MHCP) groups.

Policy Statement

MH-TCM services are eligible for Minnesota Health Care Programs (MHCP) subscribers.  

Billing

MH-TCM is   a professional service billed on an 837P cl  aim fo rmat. When billing for MH-TCM,  submit the contracting provider NPI number cu  rrently on file with Blue Plus®. In addition, an individual rendering NPI number is   required when a county contracts   providers to do this   and they bill under a Behavioral Health Clin ic, and individual NPI number is   required on the claim. Without an individual NPI,   cl  aims rej ect as needing one. When a county bills   through a Soci  al Service Agency  , an individual NPI in not needed.

Codes Modifiers Brief Description  Service Limitation

T1017 for HIS/638 and FQHC billing only     HE, HA   Face-to-face encounter (child under age 18 years)       1 unit per encounter

T1017 for HIS/638 and FQHC billing only      HE      Face-to-face encounter (age 18 or older)      1 unit per encounter


CLAIMS PROCESS

**Providers should not submit claims unless the service has been authorized by Beacon 

**Claims should be submitted on a CMS 1500 form.  

**Case management assessment (CPT Code H0031) does not require pre-authorization for adults.  

**Adult TCM is billed as a per day rate (CPT code T1016) **Child and adolescent TCM is billed per unit (CPT code T1017).

**Claims must specify ICD-10 codes, not DSM 5 codes. **Claims for unauthorized services will be denied.


Perinatal Care Coordination

Perinatal care coordination is the process of planning and coordinating care and services to meet individual needs and maximize access to necessary medical, psychosocial, nutritional, educational and other services for the pregnant woman.

Perinatal Care Coordination Service Providers must be a licensed provider in Utah and one of the following qualified providers: 

**  Registered Nurse 
**  Certified Nurse-Midwife  
**  Certified Nurse Practitioner  
**  Social Service Worker 
**  Certified Social Worker 
**  Licensed Practical Nurse who works under the supervision of a registered nurse and has additional training and experience to be a perinatal care coordinator
**  Health Educator must have either a Bachelor’s degree in health education with a minimum of three years’ experience, at least one of which must be in a medical setting, a Master’s degree with a minimum of one year of experience working in a medical setting or with pregnant women, or a Bachelor’s degree and a certificate showing completion of a certification examination in health education.

The service is reported using HCPCS T1017 Targeted Case Management, each 15 minutes.  Limited to four (4) units in a 30-day period.

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