Re: Spine Activation Code Free
Agathe Thies
Scenario 2 would include both x-ray myelography and CT spine interpretation by a single provider performing both parts (Fig 1, paths A and B). Most important, this scenario warrants the new bundled myelography codes in the last column of Table 1 and the CT spine codes in Table 2 plus Modifier 59. In this scenario, do not bill for fluoroscopic guidance, code 77003. Therefore, a patient receiving intrathecal lumbar injection + lumbar x-ray myelography + CT lumbar spine with contrast would be coded as 62304 (bundled) + 72132 + Modifier 59.
As part of routine clinical care, ICD-9-CM codes were assigned by one of nine inpatient coders, who were not aware of the study at the time of code assignment. Each hospital admission was assigned one primary diagnosis and up to 14 secondary diagnoses on the basis of the medical record including the radiology reports. Although attending physician assessments were given precedence over assessments by residents or other healthcare staff, reassignment of the ICD-9-CM codes from these sources only occurred if the attending physician documented that assessments by these sources was incorrect. Coders at this Level I trauma center are credentialed by the American Health Information Management Association. Channel Publishing or Ingenix vendor versions of the generic U.S. Department of Health and Human Services, Hospital Version ICD-9-CM code books for 2006 were used during the study time period [American Medical Association 2006; Puckett, Craig D. 2006].
Flow diagram showing patients with all fractures identified by ICD-9-CM codes versus patients without all fractures identified by ICD-9-CM codes. Of those without all fractures identified, patients were further classified into a group with only spinous process, transverse process, and chronic fractures, and a group with all other types of fractures. See Table 2 for descriptions of fractures without corresponding ICD-9-CM codes.
By level of the cervical spine (C1 to C7), coding discrepancies were even more striking. 7% of ICD-9-CM codes indicated a fractured level that was not documented in the radiology report. On the other hand, 14% of fractured levels documented by radiology report did not have a corresponding ICD-9-CM code for that fractured level.
The findings suggest that ICD-9-CM coding is relatively accurate in identifying patients who have sustained any traumatic cervical fracture, and especially if the cervical spine fracture is the primary diagnosis by ICD-9-CM code.
ICD-9-CM codes are a useful tool for clinical research because they are readily available in datasets that contain population-based information. These codes can be used to conduct epidemiological research, detect trends in the prevalence and incidence of disease, and predict patient outcome in large population-based studies [Rutledge, R. 1993; Osler, T. 1996; Faciszewski, T. 1997]. However, the potential for coding errors may cast doubt on the validity of these studies. Researchers using cervical fracture codes for clinical or epidemiological studies should refer back to the medical record, if possible, or perform a sensitivity analysis to improve accuracy in classifying these fractures. Additionally, errors in the coding process may have implications for reimbursement of hospitals when treating patients with cervical fractures since reimbursement may be based on ICD-9-CM codes in administrative databases.
A protective body sock (L0984) does not meet the definition of a brace and is noncovered.
There is no separate payment for computer-aided design/computer-aided manufacturing (CAD/CAM) technology when it is used to fabricate an orthosis. Reimbursement is included in the allowance of the codes for custom fabricated orthoses.
Evaluation of the beneficiary, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.
Payment for a spinal orthosis is included in the payment to a hospital or SNF if:
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
MODIFIERS
CG Modifier
The CG modifier must be added to code L0450, L0454, L0455, L0621, L0625, or L0628 only if it is one made primarily of nonelastic material (e.g., canvas, cotton or nylon) or having a rigid posterior panel. (Refer to the Coding Guidelines section below for instructions on the use of code A4467 for elastic spinal garments.)
When providing orthoses suppliers must:
The purpose of a rigid or semi-rigid LSO and TLSO spinal orthosis is to restrict the effect of the forces within a three-point pressure system. The posterior panel must encompass the paraspinal muscle bodies from one lateral border to another in order to provide sufficient surface area to enhance the three-point pressure system. The posterior panel must provide coverage to meet the minimum height requirements as described in the individual HCPCS codes. Spinal Orthoses that do not meet the Medicare definition of a brace should be coded as A9270.
For an item to be classified as a TLSO the posterior portion of the brace must extend from the sacrococcygeal junction to just inferior to the scapular spine. This excludes elastic or equal shoulder straps or other strapping methods. The anterior portion of the orthosis must at a minimum extend from the symphysis pubis to the xiphoid. Some TLSOs may require the anterior portion of the orthosis to extend up to the sternal notch.
Maternity support garments, which are products that are designed to provide support for the abdomen during pregnancy, do not meet the definition of a brace. These products are coded using A9270 (NON-COVERED ITEM OR SERVICE). L-codes for orthoses must not be used for these items.
Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra) (not all-inclusive)) must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).
Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra]) (not all-inclusive)) that contain stays and/or panels must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).
Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).
Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).
Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.
Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and relevant coding guideline for the criteria applicable for each HCPCS code.
Items that are not capable of providing the necessary immobilization or support to the body part for which it is designed (regardless of materials) must be coded using A9270 (NONCOVERED ITEM OR SERVICE).
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