Friday, October 9, 2015

CPT code 77063 , ICD code v76.11 or v76.12

Preventive and Screening Services— Update - Intensive Behavioral Therapy for Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy 

Digital Breast Tomosynthesis

In the CY 2015 PFS Final Rule with comment period, CMS established a payment rate for
the newly created CPT code 77063 for screening digital breast tomosynthesis mammography. The same policies that are applicable to other screening mammography
codes are applicable to CPT code 77063. In addition, since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital mammography.

Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only.

Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to claim lines with 77063 (Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).

Payment for 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12 (and
when ICD-10 is effective with ICD-10 code Z12.31). When denying claim lines for 77063
that are submitted with out the appropriate diagnosis code, the claim lines are denied using
the following messages:

• CARC 167: This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
• RARCN386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item  or service is covered. A copy of this policy is available at www.cms.mcd.search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
• Group Code CO (if GZ modifier present) or PR (if modifier GA is present).

On institutional claims:
• MACs will pay for tomosynthesis, HCPCS code 77063, on TOBs 12X, 13X, 22X, 23X based on MPFS, and TOB 85X with revenue code other than 096x, 097x, or 098x based on reasonable cost. TOB 85X claims with revenue code 096x, 097x, or 098x are paid based on MPFS (115% of the lesser of the fee schedule amount and submitted charge).

• MACs will pay for tomosynthesis, HCPCS code 77063 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or submitted charge.

• MACs will return to the provider any claim submitted with tomosynthesis, HCPCS code 77063 when the TOB is not 12X, 13X, 22X, 23X, or 85X.

• MACs will pay for tomosynthesis, HCPCS code 77063, on institutional claims TOBs 12X, 13X, 22X, 23X, and 85X when submitted with revenue code 0403 and on professional claims TOB 85X when submitted with revenue code 096X, 097X, or 098X.

• Effective for claims with dates of service on or after January 1, 2015, MACs will RTP
claims for HCPCS code 77063 that are not submitted with revenue code 0403, 096X, 097X, or 098X.

Anesthesia Furnished in Conjunction with Colonoscopy 

Section 4104 of the Affordable Care Act defined the term “preventive services” to include
“colorectal cancer screening tests” and as a result it waives any coinsurance that would
otherwise apply under Section 1833(a)(1) of the Act for screening colonoscopies. In
addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.

In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible
does not apply to anesthesia services associated with screening colonoscopies.

As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia
professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:
• Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But, MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.

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