Anthem Central Region Clinical Claims Edit

Transcription

1 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Chemodenervation of Muscles of Different Areas with Chemodenervation of Muscles of Different Area Edit: #504 Effective Date: 7/15/ /31/2099 Status: Current Last Review Date: 5/2/2013 Edit: (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral {e.g., for blepharospasm, hemifacial spasm} bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral {e.g., for blepharospasm, hemifacial spasm}) (Chemodenervation of muscle(s); neck muscle(s) {e.g., spasmodic torticollis, spasmodic dysphonia}) bundles with (Chemodenervation of muscle(s); neck muscle(s) {e.g., spasmodic torticollis, spasmodic dysphonia}) (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}) bundles with (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral {e.g., for blepharospasm, hemifacial spasm} bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral {e.g., for blepharospasm, hemifacial spasm}) (Chemodenervation of muscle(s); neck muscle(s) {e.g., spasmodic torticollis, spasmodic dysphonia}) bundles with (Chemodenervation of muscle(s); neck muscle(s) {e.g., spasmodic torticollis, spasmodic dysphonia}) (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}) bundles with (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). Page 1 of 9

2 CODE RULE CODE Rationale for Edit: Anthem Central Region bundles as redundant/mutually exclusive to 64612, bundles as redundant/mutually exclusive to 64613, bundles as redundant/mutually exclusive to 64614, bundles as redundant/mutually exclusive to, bundles as redundant/mutually exclusive to and bundles as redundant/mutually exclusive to Based on the National Correct Coding Initiative Edits, Medically Unlikely Edits, codes 64612, and may only be submitted once on a claim per date of service. Based on the AMA Current Procedure Terminology Manual, 2013, it states in parenthesis below codes and 64614: (Report only once per session) and (Report only one per session). Therefore, if is submitted with only 1 service of reimburses, if is submitted with only 1 service of reimburses, if is submitted with only 1 service of reimburses, if is submitted with ---only 1 service of reimburses, if is submitted with only 1 service of reimburses and if is submitted with only 1 service of reimburses, References: 1. Centers for Medicare and Medicaid (April 1, 2013-June 30, 2013) National Correct Coding Initiative Edits, Medical Unlikely Edits Retrieved from the World Wide Web: Page 2 of 9

3 2. American Medical Association. Destruction by Neurolytic Agent {e.g., Chemical, Thermal, Electrical or Radiofrequency), Chemodenervation-Somatic Nerves). Current Procedural Terminology, 2013: page 344. Prior Versions, if any, can be found below: Subject: Chemodenervation of Muscles of Different Areas with Chemodenervation of Muscles of Different Area Edit: #504 Effective Date: 1/01/2011-7/14/2013 Status: Prior Last Review Date: 1/1/2011 Edit: (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) (Chemodenervation of muscle(s); cervical spinal muscle(s) {e.g., for spasmodic torticollis}) bundles with (Chemodenervation of muscle(s); cervical spinal muscle(s) {e.g., for spasmodic torticollis}) (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) LT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with LT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). Page 3 of 9

4 64614-RT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with RT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles (Chemodenervation of muscle(s); muscle(s) (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}). CODE RULE CODE Redundant/ Mutually LT RT LT RT Rationale for Edit: Page 4 of 9

5 Anthem Central Region bundles as redundant/mutually exclusive with 64612, bundles as redundant/mutually exclusive with 64613, bundles as redundant/mutually exclusive with 64614, bundles as redundant/mutually exclusive with 64612LT, bundles as redundant/mutually exclusive with, LT bundles as redundant/mutually exclusive with LT, bundles RT as redundant/mutually exclusive with RT and bundles as redundant/mutually exclusive with. Based on Medicare s Medically Unlikely Edits, codes64613 and are only allowed once per date of service. Code is allowed 2 times per date of service and if this service is performed 2 times once on one side and then again on the opposite side, append modifier 50 to (). Anthem Central Region bundles 64612LT as redundant/mutually exclusive to allowing only 64612RT to reimburse and bundles as redundant/mutually exclusive to and allowing to reimburse. If chemodenervation is performed on opposite sides of the face append modifier 50 to Procedure is listed on the medically unlikely list as being a service that is allowed 2 times per date of service; therefore modifier is allowed with It is appropriate to use modifier 50 on code but not on codes or Codes or are only allowed once per date of service. References: 1. Centers for Medicare and Medicaid (July 1, 2011-October 31, 2011) Medically Unlikely Edits. Retrieved from the World Wide Web: Prior Versions, if any, can be found below: Subject: Chemodenervation of Muscles of Different Areas with Chemodenervation of Muscles of Different Area Edit: #504 Effective Date: 10/22/ /31/2010 Status: Prior Last Review Date: 1/1/2011 Edit Page 5 of 9

6 64612 (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) (Chemodenervation of muscle(s); cervical spinal muscle(s) {e.g., for spasmodic torticollis}) bundles with (Chemodenervation of muscle(s); cervical spinal muscle(s) {e.g., for spasmodic torticollis}) (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) LT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with LT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}) RT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with RT (Chemodenervation of muscle(s); extremity(s and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) bundles with (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}). (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) does not bundle with (Chemodenervation of muscle(s); muscle(s) LT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia cerebral palsy, multiple sclerosis}) does not bundle with RT (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {e.g., for dystonia, cerebral palsy, multiple sclerosis}) (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}) bundles with (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve {e.g., for blepharospasm, hemifacial spasm}). Page 6 of 9

7 CODE RULE CODE LT RT LT RT Separate Reimbursement LT Separate Reimbursement RT Separate Reimbursement Separate Reimbursement Rationale for Edit: Anthem Central Region bundles as redundant/mutually exclusive with 64612, bundles as redundant/mutually exclusive with 64613, bundles as redundant/mutually exclusive with 64614, bundles as redundant/mutually exclusive with 64612LT, bundles as redundant/mutually exclusive with, LT bundles as redundant/mutually exclusive with LT, bundles RT as redundant/mutually exclusive with RT, bundles as redundant/mutually exclusive with and bundles as redundant/mutually exclusive with Based on CPT Assistant article which states: Page 7 of 9

8 Prior to CPT 2001, codes and describe chemodenervation, including the use of botulinum toxin, of muscles of the face and neck. To reflect current clinical practice, the new code describes chemodenervation of muscles of the limbs (arm/legs) and the trunk (including rectal) muscles. CPT codes should be reported only one time per procedure, even if multiple injections are performed in sites along a single muscle or if several muscles are injected. Chemodenervation for strabismus involving the extraocular muscles is reported using code Therefore, if is submitted with only the single procedure (64612) reimburses; if is submitted with only the single procedure (64613) reimburses, if is submitted with only the single procedure (64614) reimburses, if is submitted with only the single procedure () reimburses, if is submitted with only the single procedure () reimburses, if LT is submitted with LT only the single procedure (64614-LT) reimburses, if RT is submitted with RT only the single procedure ( RT) reimburses, if is submitted with only the single procedure () reimburses and if is submitted with only the single procedure ( ) reimburses. Anthem Central Region does not bundle with, does not bundle LT with RT, does not bundles with or does not bundle with Chemodenervation may be performed on different sides of the body, such as the right leg and the left leg. If chemodenervation is performed on opposite sides of the body coding may be submitted one of two ways: 1) Submit the primary chemodenervation procedure with a modifier appended that represents the side originally injected (64614-LT) on the first line of the claim and on the second line of the claim submit RT (RT represents the opposite side of the body). With this example both chemodenervation procedures (64614-LT and RT) reimburse separately. Example #1 Date of Service CPT Code/Modifier 1/1/ LT 1/1/ RT 2) Submit the primary chemodenervation procedure without a modifier to represent the side originally injected (64614) on the first line of the claim and on the second line of the claim append modifier 50 ( ) to represent the other side of the body for the chemodenervation procedure. With this example both chemodenervation procedures reimburse separately. Page 8 of 9

9 Example #2 Date of Service CPT Code/Modifier 1/1/ /1/ Anthem Central Region does not allow Modifier 50 to be appended to procedure/code Reference Information: 1. American Medical Association. Chemodenervation. CPT Assistant, April 2001: 11(4): 1-3. Page 9 of 9