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Q: Do you know what it means when the diagnosis code is 000.0000?
Clipping from LIS formatted datafile
000.0000 is an invalid code that should force an ABN for the procedure. In this case, Screening HCV G0472 requires secondary diagnosis or age requirements that can not be put in the data file in a way an LIS system can handle. Specifically, 210.3 requires 2 diagnosis codes Z72.89 and F19.20 for payment. Alternatively, the single diagnosis code Z11.59 can only be used for patients born between 1945 and 1965. Since these are complex rules, the safest thing to do is to obtain an ABN or risk losing revenue on this procedure.
Q: We are noticing several CPT® codes with 000.0000 built as DX code in the codemap files. What is the purpose of this build?
A: 000.0000 specifies there are no covered diagnosis for the procedure and you should always obtain an ABN. This is due to a specific policy that states these procedures are never covered, or there are secondary coverage requirements which are too complex to put into an LIS. For example, one diagnosis from list A and one diagnosis from list B are required for medical necessity.
Q: We have noticed that Z00.0 is not firing an ABN for Vitamin B12 for routine physicals.
A: B-12 (82607) is not covered by an NCD or LCD in your jurisdiction that would limit coverage to a certain set of diagnosis, so all will pass. However, the dx you reference (Z00.0) is a special code which is never covered by Statute for a diagnostic lab service. Codes on this non-covered list do not require an ABN, and the patient may be billed directly without billing Medicare first. Please review the relevant section of the NCD manual with the list. https://www.codemap.com/file/Non-Covered.pdf
Q: I have users stating that E11.621 is an acceptable diagnosis for CPT 99183, however, I do not see it in our file.
A: This refers to the diagnosis codes contained in NCD 20.29. The codes in your file are from the single diagnosis code requirement in the first section of Tab "ICD Diagnosis”. E11.621 is an allowed code but only if also submitted with a code from a secondary set of codes. Please see the two sections below the single list titled:
"Group 1 for Dual Diagnosis Codes: Wound Codes. A Diabetes code plus a Wound code (a code from Group 1 & Group 2) must be used together to satisfy medical necessity"
These secondary code requirements are not possible to put into your HIS format. Therefore we can only include the single diagnosis code requirements in the file.
Adding further confusion to NCD 190.3, National Government Services today issued a News Alert instructing providers they have looked at the list of Discretionary Covered Indications of NCD 190.3 and decided that 48 out of the 661 codes contained in the Discretionary list of covered codes will be covered for Cytogenetic Procedures within the NGS Jurisdiction. Rather than using the well tested method of listing covered diagnosis requirements in an LCD with notice and comment periods, effective dates, appeals processes, etc... we'll just put it an email newsletter. I'm sure the NGS customer service representatives will be well educated on this. :-| CodeMap is working on adding these codes to datafiles for customers billing to NGS.
Q: Can you please review NCD 210.6, specifically codes 86706 and 87340. Our clearinghouse is stating these CPT’s need to go through Medical Necessity, but they are not in our Codemap file.
A: 210.6 is a screening benefit which requires specific diagnosis codes only if these tests are run for the purpose of the screening benefit. There are no diagnosis code restrictions at the NCD or your LCD level for Hepatitis B diagnostic tests.
CMS created code G0499 to be used for the screening benefit but only for non-pregnant beneficiaries. For pregnant beneficiaries, you would have to use one of the diagnostic procedure codes (86706, 87340) and a combination of 2 diagnosis codes including a supervision of pregnancy dx. Bottom line, if we put these requirements in the file, all diagnostic Hepatitis B procedures would be required to meet these narrow requirements for a pregnant medicare patient or generate an ABN. In other words, every claim for the diagnostic Hep B tests would require an ABN which is probably something you do not want to do.
Q: Our Indiana MAC has a policy L36805 which is not appearing in our CodeMap Data Files. Why not?
A: L36805 has no associated diagnosis codes for the CPT codes contained in the policy. This is typical of a contractor Article although it is currently marked as an LCD. Without a list of diagnosis codes, there are no codes specified for Medical Necessity checking.