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National Osteoporosis Foundation

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Professional Series

A Reference Guide for Osteoporosis Reimbursement Policy for Healthcare Professionals

NATIONAL OSTEOPOROSIS FOUNDATION

Billing and Reimbursement Guide

1

National Osteoporosis Foundation

A Reference Guide for Osteoporosis Reimbursement Policy for Healthcare Professionals

June 2008

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CONTENTS

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Online Updates During July 2008, Congress agreed to a 1.1 percent increase in Medicare physician reimbursement which the President signed into law.  For the most recent Medicare reimbursement information, we recommend going to http://www.cms.hhs.gov/home/medicare.asp or contacting your local contractor, whose information is in Section IX – Reimbursement Tools and References. 1

Table of Contents

2

Acknowledgements

5

Updates

5

Disclaimer

5

How to Use This Guide

7

Introduction to Osteoporosis

8

I. Overview of Coding, Coverage and Payment Coding Systems Overview ICD-9-CM Diagnosis Codes ICD-9-CM V Codes ICD-9-CM Procedure Codes Current Procedural Terminology (CPT) Codes Level 2 – National Level HCPCS Codes National Uniform Billing Committee Codes (Revenue Codes) National Drug Codes Coverage and Payment Payer Overview: Medicare Payer Overview: Medicaid Payer Overview: Private Payer Payment Systems Overview Medicare Payment Systems Hospital Inpatient Hospital Outpatient Physician Office Other Payment Methodologies Overview of Key Payers for Osteoporosis and Related Conditions

9 9 10 11 11 11 12 12 12 12 13 13 14 14 14 15 15 15 16 18

II. Diagnostic Tests Bone Density Tests and Vertebral Fracture Risk Assessments Procedures Quantitative Computed Tomography (QCT) and Quantitative Ultrasound (QUS) Procedures Bone Biopsies Procedures Laboratory Procedure Coverage and Payment for Diagnostic Testing: Medicare Medicare Coverage Modifiers Medicare Payment for Physicians and Outpatient Facilities Medicare Payment for Inpatient Services Coverage and Payment for Diagnostic Testing: Medicaid Medicaid Coverage for Physicians and Facilities Medicaid Payment for Physicians and Facilities Coverage and Payment for Diagnostic Testing: Private Payer Private Payer Coverage for Physicians and Facilities Private Payer Payment for Physicians and Facilities

19 20 20 23 23 24 24 25 25 26 26 29 31 35 37 37 37 38 38 38

III. Physician-Administered Drugs ICD-9-CM Diagnosis Codes HCPCS Coding for Physician-Administered Drugs National Drug Code (NDC) Coding for Drug Administration Revenue Codes Medicare Coverage for Physicians and Facilities Payment for Physicians and Facilities Physician Fee Schedule

39 39 40 41 41 42 43 43 43 43

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Hospital Outpatient Prospective Payment System Reimbursement for Physician-Administered Drugs Medicaid Private Insurance

45 45 46 46

IV. ­­­Oral and Self-Administered Therapies Oral Therapies for Osteoporosis

49 49

National Drug Codes for Oral and Self-Administered Drugs Payment for Oral and Self-Administered Therapies Understanding Common Prescription Benefit Structures Formularies Drug Utilization Mechanisms Medicare Prescription Drug Benefit Requesting Part D Formulary and Tiering Exceptions Medicaid Prescription Drug Coverage Medicaid Prescription Drug Coverage Drug Utilization Restrictions Preferred Drug Lists (PDLs) Prior Authorization Requirements Private Payer Prescription Drug Coverage

49 50 50 51 51 52 52 52 52 53 53 53

V. Orthopedic–Inpatient Types of Fractures Diagnosis Coding V-Codes Procedure Coding Revenue Codes Medicare Coverage and Payment Medicaid Coverage and Payment Private Insurance Coverage and Payment

55 55 55 56 57 58 58 60 60

VI. Orthopedic–Outpatient Diagnosis Coding Procedure Coding for Vertebroplasty and Kyphoplasty for Compression Fractures of the Spine Modifiers Coding for Evaluation and Management Services (Office Visits) Consultations Medicare Coverage and Payment Coverage Payment Medicaid Coverage and Payment Private Payer Coverage and Payment

61 61 62 63 63 64 65 65 65 68 68

VII. Inpatient Physical and Occupational Therapy Diagnosis Coding V-Codes Coding for Therapeutic Procedures Revenue Codes Medicare Coverage and Payment Coverage Payment Medicaid Coverage and Payment Private Payer Coverage and Payment Physical and Occupational Therapy Provided in the Skilled Nursing Facility (SNF) Medicare Coverage Medicare Payment Medicaid Coverage and Payment Private Payer Coverage and Payment

69 69 69 70 71 72 72 72 73 74 74 74 75 76 76

3 CONTENTS

VIII. Outpatient Physical and Occupational Therapy Diagnosis Coding Procedure Coding Modifiers Revenue Codes Medicare Coverage and Payment Coverage Payment Medicaid Coverage and Payment Private Payer Coverage and Payment

77 77 77 79 79 80 80 81 84 84

­IX. Reimbursement Tools and References 85 Checklist for Verifying Benefits 86 CMS 1500 Claim Form—Example 1 87 Sample CMS 1500 Claim Form—Example 2 88 Sample CMS 1450/UB-40 Claim Form 89 Sample Letter of Medical Necessity 90 Claim Denials and Appeals 91 Common Reasons for Claim Denial 91 Recommended Items for an Appeals Packet 91 Best Practices for Appealing Denied Claims 92 Sample Letter of Appeal 93 Sample Prior Authorization Request 94 Checklist for Obtaining Prior Authorization 95 Medicare Advanced Beneficiary Notice 95 Sample Advanced Beneficiary Notice 96 Notice of Exclusions from Medicare Benefits 97 Glossary 99 State Medicaid Contact Information 103 State Department of Insurance Contact Information 105 Medicare Carriers Contact Information 107 Medicare Fiscal Intermediaries Contact Information 109 Medicare Part A/B MACs Contact Information 110 Manufacturer Sponsored Patient Assistance Programs Contact Information 110 Comprehensive List of Codes Relating to Osteoporosis 111-124 X. Patient Tools Paying for Your Osteoporosis Medications: What You Need to Know

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125 127

The National Osteoporosis Foundation would like to thank the following organizations and individuals for their valuable contributions to the development of this billing and reimbursement guide.

Acknowledgements

We are grateful to all the members of the Advisory Committee who spent many hours reviewing and analyzing the contents of the guide. We particularly appreciate the chair’s role in helping to oversee the conceptualization of the guide. Advisory Committee: Angelo Licata, MD, PhD, Chair; F. Michael Gloth, MD; C. Conrad Johnston, Jr., MD; John Kaufman, MD; Cheryl Lambing, MD; Joseph Lane, MD; Michael Maricic, MD; Diane Maroun, CPC, CEC; Alfred Moffett, MD; Joan Neuner, MD, MPH; Jeri Nieves, PhD; Bradford Richmond, MD. We appreciate their willingness to advise NOF during the creation of this guide. We also thank Amanda Bashant of the AmerisourceBergen Specialty Group of XcendaTM for her good counsel, Shannon von Felden of the National Osteoporosis Foundation for skillful editing and Roberta Biegel of the National Osteoporosis Foundation for envisioning the project and shepherding it to completion. We are indebted to Amgen Corporation and Mr. Kenneth Chen, without whom this guide would never have been written or published. They believed in the need for this reference manual and the importance of creating a living document that would assist professionals to diagnose and treat patients with osteoporosis. They also valued the publication of the accompanying education tool for patients so that they could navigate our complex healthcare system. Amgen Corporation provided an unrestricted grant for the creation and printing of the guide and patient material.

For current updates, please log on to www.nof.org/reimbursement.

The information contained in this billing guide is intended to assist you in understanding the healthcare reimbursement process. We recommend that you consult your own legal or billing advisor and billing and coding specialist for specific guidance in this area. Also, we strongly suggest that you consult individual payer organizations for specific information on local coverage and reimbursement policies.

Updates

Disclaimer

The information contained in this billing guide is current as of January 2008. All coding should always accurately reflect the services provided and should be consistent with the policies of each payer.

5 Acknowledgements & Disclaimer

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The National Osteoporosis Foundation (NOF) has developed this billing and reimbursement guide to assist you with reimbursement issues you may encounter in your treatment of patients with osteoporosis. NOF is the nation’s leading voluntary health organization solely dedicated to preventing osteoporosis, promoting lifelong bone health, helping to improve the lives of those affected by osteoporosis and related fractures and to finding a cure. NOF achieves its mission through programs of awareness, advocacy, public and health professional education and research. NOF hopes this guide will help you navigate today’s complex healthcare reimbursement environment.

How to Use This Guide

Coding, coverage and payment for the procedures, services and medications discussed in this billing guide vary significantly depending on the payer, provider type and site of service. Therefore, NOF recommends that you check with specific payers in your area to determine local policies. The guide begins with an introduction to osteoporosis and a brief overview of coding, coverage and payment related to this condition. The introduction also provides an overview of key payers for osteoporosis. Subsequent chapters are designed to provide key information on coverage and reimbursement for each of the following: • Diagnostic tests • Physical and occupational therapy • Orthopedic procedures • Physician-administered, self-administered and oral medications A reimbursement tools section is included in the back of the billing guide and includes many items you may find useful as you navigate coverage and reimbursement issues with particular payers and work to educate your patients. In this section, we provide the following: • Checklist for benefit verifications • Sample claim forms • Sample letter of medical necessity • Sample letter of appeal and a checklist • Claim denial checklist • Sample prior authorization request and checklist • Medicare advanced beneficiary notice (ABN) • Glossary of key terms and phrases • Medicare and Medicaid contact information • Information on state insurance agencies • C  omprehensive list of codes relating to osteoporosis prevention, diagnosis and treatment • P  atient tools, including contact information for the Social Security Administration Low Income Subsidy and Prescription Assistance Programs 7 How to Use this Guide

Introduction to Osteoporosis

Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures, especially of the hip, spine and wrist. In 2005, osteoporosis was responsible for approximately two million fractures, including an estimated: • 300,000 hip fractures; • 547,000 vertebral fractures; • 397,000 wrist fractures; and • 809,000 fractures at other sites.1 According to the Centers for Medicare & Medicaid Services (CMS), one out of every two women over the age of 50 and one in four men over the age of 50 will have an osteoporosis-related fracture in their lifetime.2 Of special concern are fractures of the hip and spine. A hip fracture almost always requires hospitalization and major surgery. It can impair a person’s ability to walk unassisted and may cause prolonged or permanent disability, or even death. Twenty percent of seniors who suffer a hip fracture die within one year.3 Spinal or vertebral fractures also have serious consequences, including loss of height, severe back pain and deformity. Osteoporosis is a major public health threat for an estimated 44 million Americans or 55 percent of people 50 years of age and older. In the United States, 10 million individuals are estimated to already have the disease and almost 34 million more are estimated to have low bone mass, placing them at increased risk for osteoporosis.4

1. National Osteoporosis Foundation (NOF), Osteoporosis Fast Facts. 2. Centers for Medicare & Medicaid Services, National Osteoporosis Prevention and Awareness. 3. Ibid. 4. National Osteoporosis Foundation (NOF), Osteoporosis Fast Facts. 8

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­­­Section 1 Coding is the language that allows payers and providers to communicate. Providers identify diseases and conditions, procedures, drugs, devices and other health-related items provided to patients through coding systems. These codes are reported on claims forms sent to payers which allows payers to form coverage policies and determine payment for health care services.

Overview of Coding, Coverage and Payment

Coding Systems Overview Diseases and conditions, procedures, drugs and devices are reported using several different coding systems including: • I nternational Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)5 • Current Procedural Terminology (CPT)6 • Healthcare Common Procedure Coding System (HCPCS)7 • National Uniform Billing Committee Revenue Codes • National Drug Code (NDC) The following table contains an overview of these coding systems.

5. International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2008 Expert, Ingenix, 2007 6. Current Procedural Terminology (CPT® 2008), Professional Edition, American Medical Association, 2007 7. HCPCS Level II, 2008 Expert, Ingenix, 2007 9 I. Coding, Coverage & Payment

Table 1. Overview of Coding Systems ICD-9-CM

Diagnosis Codes

Describe the patient’s condition and status. These codes demonstrate the need for services and supplies ordered by the health care provider.

Procedure Codes

Numeric codes used to describe services performed in the hospital setting.

CPT8

Descriptive, five-digit numeric codes used to report medical services, including professional evaluation and management services, procedures and tests.

HCPCS

Level II National Codes

Alpha-numeric codes used to describe products, including pharmaceutical agents, medical equipment and supplies required for a patient’s care.

Level III (Local Codes)

Alphanumeric codes assigned by local payers to describe supplies, services, or drugs not described by existing national HCPCS or CPT codes. Most of these codes were phased out in 2003.

National Uniform Billing Committee Codes

Revenue Codes

Categorize hospital services by revenue center.

National Drug Code (NDC)

Drug Codes

Universal product identifier for drugs.

8

Providers report the drugs, services and procedures provided to the patient with the patient’s diagnosis on the appropriate claim form using the various code sets. There are two primary claim forms providers use to report services to payers. Providers such as physicians and durable medical equipment suppliers use the CMS 1500 claim form. Hospitals, home health agencies, nursing homes and other institutional providers use the CMS-1450/UB 04 claim form. A sample version of each claim form is included in the back of this billing guide. ICD-9-CM Diagnosis Codes Healthcare providers and payers use ICD-9-CM codes to describe the patient’s condition and status for that encounter. The provider describes why a service or supply is medically necessary in the patient’s medical record. This information is converted to an ICD-9-CM diagnosis code so it can be reported to payers on the claim form. 8. CPT codes are also known as HCPCS Level I Codes. CPT is a trademark of the American Medical Association. 10

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ICD-9-CM diagnosis codes are three to five-digit numeric or alpha-numeric codes that reflect the patient’s condition, illnesses and symptoms. Patients may have multiple illnesses or symptoms that may be reported with multiple ICD-9-CM diagnosis codes on the claim form. Also, one ICD-9-CM diagnosis code may represent more than one condition. Codes should be used at their highest specificity. Diagnoses documented as “probable, suspected, questionable, or Rule Out” should not be used. They are not confirmed diagnoses. One should use the signs or symptoms as the reason for the encounter. ICD-9-CM V Codes There are occasions when circumstances other than a disease or an injury justify an encounter with the health care delivery system and are recorded as “problems” or “diagnoses”. V codes are used in these circumstances, which can arise in one of three ways: • A  person who is not currently sick utilizes health care services for a specific purpose (e.g. organ donation). This is a rare occurrence in the hospital inpatient setting and may be more common in the hospital outpatient and physician office settings. • A  person with a known disease or injury encounters the health care system for a specific treatment related to that disease or injury (e.g. cast change). • A  circumstance or problem is present which influences an individual’s health but is not in itself a current illness or injury. ICD-9-CM Procedure Codes ICD-9 CM procedure codes are numeric codes used to report procedures performed in the inpatient hospital setting of care or other institutions, and are found in Volume 3 of the ICD-9-CM. ICD-9-CM procedure codes are 3 to 5 numeric digits with each additional digit providing additional specificity about the condition, disease or symptom. Current Procedural Terminology (CPT) Codes Physicians primarily use CPT codes to report professional services and procedures. Hospital outpatient facilities may also use CPT codes in combination with revenue codes to specify procedures and services provided. The AMA, with input from specialty medical associations, and government and private payers, updates CPT codes on a bi-annual basis. Codes should be used at their highest specificity. Diagnoses documented as “probable, suspected, questionable, or Rule Out” should not be used. They are not confirmed diagnoses. One should use the signs or symptoms as the reason for the encounter. CPT codes may be used to report many procedures such as diagnostic testing for osteoporosis, stabilization of a fracture and injection services. Modifiers are two digit codes reported in conjunction with CPT codes to “indicate 11 I. Coding, Coverage & Payment

that a service or procedure has been altered by some specific circumstance but not changed in its definition or code.”9 Using appropriate modifiers is important for providers to be compliant with the AMA’s ground rules for using CPT codes. Level 2 – National Level HCPCS Codes HCPCS Level 2 codes (more commonly referred to as HCPCS codes) are five-digit alpha-numeric codes used to describe services, products, including pharmaceutical agents, equipment and supplies. CMS created HCPCS codes to describe services and procedures that do not have CPT codes, but there is a need on the part of government and private payers to have a code that accurately describes the item, service or procedure. National Uniform Billing Committee Codes (Revenue Codes) Generally referred to as revenue codes, these codes categorize hospital services by revenue center. These codes are important for capturing cost data by department, which can then be used by Medicare and Medicaid for cost reporting. For Medicare purposes and most other payers revenue codes must be included for each service on the UB-04 claim form. Revenue codes are also sometimes used to determine if charges itemized under a specific revenue code are separately reimbursable or are included in a global reimbursement or packaged into a rate paid to the facility. National Drug Codes The National Drug Code (NDC) system is used as a universal product identifier. The U.S. Food and Drug Administration (FDA) assigns each drug product listed under Section 510 of the Food, Drug and Cosmetic Act a unique number called the NDC that identifies the drug manufacturer or distributor, drug strength, dosage or formulation and package size. Retail pharmacies primarily use NDCs for billing and reimbursement purposes.

Coverage and Payment Coverage for prescription drugs, doctor’s office visits, hospital stays, outpatient therapy and other medical expenses will vary widely among different payer types and insurance plans. In order for your office or facility to receive appropriate reimbursement for the services and treatments you provide, it is important that you understand the coverage and benefits of your patients’ health insurance policies. There are a number of factors that may influence how payers will cover and reimburse for services and therapies provided to patients including benefit type, payer type and site of service. Throughout this guide we will discuss coverage and pay9. AMA CPT® 2007—Introduction, Instructions for Use, page xiv, Modifiers. 12

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ment for services and therapies related to osteoporosis by Medicare, Medicaid and private payers in different sites of service (e.g. hospital inpatient, hospital outpatient, physician office). Payer Overview: Medicare Medicare is a federally funded health insurance program, providing coverage to approximately 44 million beneficiaries. Currently overseen by the CMS, Medicare provides health insurance for individuals 65 and older, disabled individuals qualifying for Social Security benefits and individuals with end-stage renal disease (ESRD). The Medicare program consists of the following four parts: • P  art A provides coverage for inpatient services, such as hospitalizations, hospice care, skilled nursing facility stays and home health services. • P  art B provides reimbursement for physician services, hospital outpatient services, durable medical equipment and some home health services. Covered services include drugs that are “not usually self-administered” and their administration. • P  art C allows beneficiaries to receive their Medicare benefits through managed care plans. • P  art D provides an outpatient prescription drug benefit to Medicare beneficiaries. Payer Overview: Medicaid Medicaid is a joint venture between federal and state governments to provide health insurance coverage to individuals with low incomes that meet certain medical criteria. Within broad national guidelines, each state is allowed to perform the following activities: • Establish eligibility standards • Determine the type, amount, duration and scope of services • Set the rate of payment for services • Administer its program Each of these elements plays a role in determining who is eligible for Medicaid, what services the recipient is eligible to receive and how the program will cover and reimburse those services. The federal government requires that states must provide certain types of medical services to individuals who are entitled to full Medicaid benefits. Other benefits are optional; states can choose to add them to their core benefit package. The table that follows outlines mandatory and optional Medicaid benefits.

13 I. Coding, Coverage & Payment

Table 2. Medicaid Benefits Mandatory Benefits

Optional Benefits

Physician services (including physicianadministered drugs)

Prescription drugs

Inpatient hospital services

Durable Medical Equipment (DME)

Outpatient hospital services

Intermediate care facility services

Payer Overview: Private Insurers The type of private health insurance coverage an individual has can impact the scope of covered benefits and out-of-pocket expenses for medical services. Health insurance plans are generally described as either indemnity (fee-for-service) or managed care. Indemnity and managed care plans differ in their basic approaches. In general terms, the major differences concern choice of providers, patient out-of-pocket costs for covered services and how claims are reimbursed. Typically, indemnity plans offer more open access to physicians, specialty providers, hospitals and other health care providers than managed care plans but have higher costs for the patient. Managed care plans, by contrast, which include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Point of Service (POS) plans, usually restrict access to certain hospitals and physicians in exchange for lower patient costs. Payment Systems Overview Medicare Payment Systems Table 3 outlines the Medicare payment systems for the hospital inpatient, hospital outpatient, physician office and laboratory settings. Table 3. Medicare Payment Methodologies by Site of Service

14

Site of Service

Payment System

Payment Based On

Hospital Inpatient

Diagnosis Related Group (DRG)

Hospital Outpatient Services

Inpatient Prospective Payment System (IPPS) Outpatient Prospective Payment System (OPPS)

Physician Office

Medicare Physician Fee Schedule (MPFS)

Current Procedure Terminology (CPT) and Health Care Common Procedure Coding System Level II (HCPCS)

Laboratory Services

Clinical Laboratory Fee Schedule (CLAB)

CPT and HCPCS

Ambulatory Payment Classification (APC)

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Hospital Inpatient The Inpatient Prospective Payment System (IPPS) is a prospective payment system based on Diagnosis-Related Groups or DRGs. Under the IPPS, patient categories are defined by ICD9CM diagnosis codes and procedural codes (not CPT codes) and are modified by age, complications, co-existing conditions or discharge status. DRGs group patients with the same conditions, and anticipate the level of care required during hospitalization. Under the IPPS, hospitals are paid based on what the hospitalization was expected to cost instead of its actual cost. Hospitals are paid for one DRG per patient encounter and reimbursement for all services rendered during the hospital stay is bundled into that one payment. Hospital Outpatient The Hospital Outpatient Prospective Payment System (OPPS) is a payment system based on Ambulatory Payment Classifications or APCs. A hospital bills CPT and HCPCS codes for services rendered on a UB-04 claim form (see sample in the back of this guide) and these codes map to specific APCs. APCs classify services into groups that are similar clinically and require similar resources. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC per patient encounter. Medicare reimburses for certain drugs known as Specified Covered Outpatient Drugs (SCODs) separately in the hospital outpatient setting. Medicare reimburses hospital outpatient departments for SCODs based on 105 percent of average sales price (ASP). The ASP is the average sales price from a manufacturer to all purchasing entities who obtain the product from the manufacturer (such as wholesalers and distributors). Every quarter, manufacturers submit sales data to CMS to calculate a product’s ASP. There is a two quarter lag between when manufacturers report actual ASP data to CMS and when CMS uses that data to establish the payment rate. In cases where CMS has not yet published the ASP for a given drug – such as when newer drugs hit the market – reimbursement is based instead on the drug’s wholesale acquisition cost (WAC), as published in pricing compendia such as RedBookTM, plus 5 percent. Physician Office Medicare pays for services provided in the physician office according to the Medicare Physician Fee Schedule (PFS), which is based on the Resource Based Relative Value Scale (RBRVS). Under this payment system, CMS assigns each procedure a relative value unit (RVU) that includes three components, reflecting: • Physician work involved in the service • Practice expense generated by the service • C  ost of professional liability (malpractice) insurance needed to provide the service 15 I. Coding, Coverage & Payment

To determine the national average payment amount for a specific service, each RVU is multiplied by a national conversion factor that is updated annually and published with the PFS. Specific payment amounts for individual practices are obtained by factoring in the geographic practice cost index (GPCI) for the geographic fee schedule area to adjust for differences in local practice costs. Medicare reimburses for certain drugs administered in the physician office based on 106 percent of ASP. Other Payment Methodologies Many Medicaid programs as well as private insurance plans utilize payment systems similar to those described above for Medicare. However, additional payment methodologies such as per diem reimbursement, capitation and usual and customary charges may be used depending on the payer and site of service. Throughout this billing guide, we will discuss Medicaid and private payer coverage and reimbursement for osteoporosis-related procedures, services and drugs. Table 4 provides a summary of various reimbursement methodologies that may be utilized by different payers.

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Table 4. Payment Methodologies Payment System

Description

Capitation

• All-inclusive payments by procedure, time period, or member • Physician is paid a fixed amount per member, per month. • T  ypically utilized only by Health Maintenance Organizations (HMOs) • Specialty services can be carved out from the capitated rate

Per Diem

• Prospective payment method with payment set in advance • P  ayment is bundled for all services provided and is based on an established, per-day amount • Rates may differ depending on intensity of service

Percentage of Billed Charges

• R  eimbursement based on a percentage of charges billed by health care provider • T  he percentage is contractually negotiated and varies with each provider

Usual, Customary and Reasonable (UCR)

• A  mount paid by a health plan based on a combination of the reasonable fee for the service, the customary fee charged by physicians in a specific locality and the physician’s usual fee

Contracted Rates

• R  eimbursement for services and products most often dictated by contractual relationships • P  rivate payers reimburse providers a fixed and negotiated rate, based on individual contracts • R  ates are often negotiated down to specific CPT codes per contract. • In-network physicians agree to provide services at a discount of the normal fee

17 I. Coding, Coverage & Payment

Overview of Key Payers for Osteoporosis and Related Conditions Figure 1 shows a breakdown of key payers for osteoporosis in the outpatient10 and inpatient11 settings. Medicare is the largest payer for osteoporosis and this can be attributed to patient characteristics, such as age, that are shared between individuals diagnosed with osteoporosis and Medicare recipients. It is important to note that the data contained in the inpatient pie chart may be skewed toward Medicare because patients treated in the inpatient setting tend to be older and sicker, which is more reflective of the Medicare population in general. Private payers are a slightly less significant payer source for osteoporosis. “Other payers” may include government payers [i.e. Department of Veterans Affairs (VA), TRICARE], worker’s compensation, unknown payers and uninsured or self-pay individuals.

Figure 1. Outpatient and Inpatient Payer Mixes for Osteoporosis (ICD-9-CM 733.0) Other 9%

Other 2% Medicaid 13%

Private Insurance 26%

Medicaid 3%

Private Payer 11%

Medicare 53% NAMCS/NHAMCS—Outpatient

Medicare 84% NIS—Inpatient

10. The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001-2004. 11. National Inpatient Sample (NIS), 2001-2004. 18

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­­­Section 2 Several screening tests for osteoporosis are available; however, coverage and payment for these services varies by payer. In this section, we will review procedure coding for bone density tests, vertebral fracture risk assessments, quantitative computed tomography (QCT), quantitative ultrasound (QUS), bone biopsies and laboratory services. We will then discuss coverage and payment for diagnostic tests by Medicare, Medicaid and private payers.

Diagnostic Tests

The diagnoses covered for the various diagnostic tests will vary by payer. Table 5 shows a list of the ICD-9-CM diagnosis codes that may be appropriate for physicians and facilities to report diagnostic testing to payers. Table 5. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Condition12 ICD-9-CM Diagnosis Codes and Descriptions Osteoporosis

733.00

Unspecified osteoporosis

733.01

Senile osteoporosis (Postmenopausal)

733.02

Idiopathic osteoporosis

733.03

Disuse osteoporosis

733.09

Other osteoporosis (drug-induced)

V17.81

Family history of osteoporosis

733.90

Disorder of bone and cartilage, unspecified

793.7

Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture

733.10

Pathologic fracture, unspecified site

733.11

Pathologic fracture of humerus

733.12

Pathologic fracture of distal radius and ulna (Wrist NOS)

733.13

Pathologic fracture of vertebrae (Collapse of vertebrae)

733.14

Pathologic fracture of neck of femur (Femur/Hip NOS)

733.15

Pathologic fracture of other specified part of femur

733.16

Pathologic fracture of tibia and fibula (Ankle NOS)

733.19

Pathologic fracture of other specified site

V54.20-V54.29

Aftercare for healing pathologic fracture (Site specific)

Fracture of Neck and Trunk

805.00-829.1

Fracture of Neck and Trunk (site specific)

Diseases of Endocrine Glands

252.0x

Hyperparathyroidism

12. International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2008 Expert, Ingenix, 2007 19 II. Diagnostic Tests

Table 5. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Condition (continued) ICD-9-CM Diagnosis Codes and Descriptions 255.0

Cushing’s syndrome

256.2

Postablative ovarian failure

256.31

Premature menopause (permanent cessation of ovarian function)

256.39

Other ovarian failure

259.3

Ectopic hormone secretion, not elsewhere classified (hyperparathyroidism)

268.2

Osteomalacia

268.9

Unspecified vitamin D deficiency

627.x*

Menopausal and postmenopausal disorders

V07.4

Hormone replacement therapy (postmenopausal)

V49.81

Asymptomatic postmenopausal status (age-related) (natural)

*X = Additional digit required. Truncated codes are denied by payers.

One or more diagnosis codes may be required to indicate medical necessity. Some payers do not cover services performed for preventative or screening tests. When osteoporosis is suspected, physicians should report documented signs, symptoms, illnesses or injuries that may be covered instead of “screening” codes, as appropriate. Bone Density Tests and Vertebral Fracture Risk Assessments Screening and initial bone loss diagnosis can be accomplished by bone mineral density (BMD) tests that measure the strength and mass of bones. BMD tests require no surgical intervention and are a reliable way to determine loss of bone mass. It is important to note that industry terms including “bone mineral density,” “bone density study,” “bone densitometry,” and “bone mass measurement” are often used interchangeably to describe obtaining bone mass measurements and assessing fracture risk. Claims for BMD studies performed as a baseline for subsequent monitoring by another testing modality are coded with diagnosis code — 793.7 Nonspecific abnormal findings on radiological and other examination. All payers recognize these codes for all sites of service. Procedures BMD testing is used as a screening tool for osteoporosis, to evaluate the disease of bone and to review the responses of bone disease to treatment over time. The most 20

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common methods to measure BMD and access fracture risk involve central (axial) and peripheral dual energy x-ray absorptiometry (DXA or pDXA) scan. Dual energy x-ray absorptiometry (DXA) scanning is a two-dimensional projection system that involves two special low-radiation x-ray beams with different levels of energy being pulsed alternately. DXA scans can detect even very small amounts of bone loss. The most widely accepted method for measuring BMD13 uses machines which measure density in the hip, spine and total body. Peripheral dual energy x-ray absorptiometry (pDXA) measures the bone density in the forearm, wrist, finger, shinbone and heel. DXA of the femoral neck is the best validated test to predict hip fracture and is comparable to forearm measurements for predicting fractures at other sites.14 Table 6 lists codes appropriate to describe bone densitometry by DXA in the outpatient and inpatient settings. Table 6. CPT and ICD-9-CM Procedure Codes for Bone Densitometry by DXA

CPT/ICD-9-CM Codes and Descriptions DXA 77080

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (central or axial) (e.g. hips, pelvis, spine)

CPT category I codes are used by physician offices and hospital outpatient clinics

77081

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)

77082

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture risk assessment

0028T

Dual energy x-ray absorptiometry (DXA) body composition study, one or more sites

CPT category II codes are used by physician offices and hospital outpatient clinics

88.98

Bone mineral density studies Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

ICD-9-CM procedure codes are used by inpatient hospital facilities

CPT Codes 77080 and 77081 are reported when measuring BMD at a specific location as depicted in the code description. In addition, CPT code 77080 is reported for monitoring osteoporosis drug therapy. CPT code 77082 is reported for one or more vertebral sites to assess fracture risk. Temporary CPT Category III code 0028T allows data collection in the event a unique CPT Category I procedure code 13. Department of Health and Human Services, Bone Health and Osteoporosis, Report of the Surgeon General, 2004. 14. .Agency for Healthcare Research and Quality (AHRQ),Evidence Report/Technology Assessment No 28, January 2001. 21 II. Diagnostic Tests

does not exist for the specific DXA procedure performed by the provider (e.g. multiple DXAs). There are two other x-ray absorptiometry scans used to determine bone mass. The single-energy x-ray absorptiometry (SEXA) measures the bone density in the wrist or heel. Radiographic absorptiometry (RA) scans use an x-ray film of the hand and a small metal wedge to calculate bone density. The codes that may be appropriate to report SEXA and RA in the outpatient and inpatient setting are listed in Table 7. Table 7. CPT and ICD-9-CM Procedure Codes for Bone Densitometry by Other X-Ray Absorptiometry CPT/HCPCS/ICD-9-CM Codes and Descriptions Other X-ray Absorptiometry 77083

Radiographic absorptiometry (e.g. photodensitometry, radiogrammetry), 1 or more sites

CPT category I codes are used by physician offices and hospital outpatient clinics

G0130

Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

HCPCS codes are used by physician offices and hospital outpatient clinics

88.98

Bone mineral density studies Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

ICD-9-CM procedure codes are used by hospital facilities

Temporary HCPCS code G0130 may be used to report the single energy x-ray absorptiometry (SEXA) until a more permanent CPT code becomes available. Bone mass can also be measured with single and dual photon energy beam absorption and efficiency studies across one or more sites. This provides a quantitative measurement of the BMD and can also be used to assess the individual’s response to treatment. CPT and ICD-9-CM procedure codes that may be appropriate for photon absorptiometry are listed in Table 8. Table 8. CPT and ICD-9-CM Procedure Codes for Bone Densitometry by Photon Absorptiometry CPT/ICD-9-CM Codes and Descriptions Photon Absorptiometry 78350

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry (SPA)

7835

Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

88.98

Bone mineral density studies Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

22

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital facilities

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QUANTITATIVE COMPUTED TOMOGRAPHY (QCT) AND QUANTITATIVE ULTRASOUND (QUS) Other common forms of bone densitometry measurements include quantitative computed tomography (QCT) and quantitative ultrasound (QUS). Central and peripheral computed tomography (CT) scans are also used to obtain QCT bone mass measurements. Like DXA, this technique is based on the emission of ionizing radiation but uses computerized tomography as the imaging modality to produce thin cross-sectional views of various layers of the body. The central QCT scans the bones of the hips, pelvis and lower spine while the peripheral QCT (pQCT) measures the bone density at the radius, wrist, forearm and heel. Procedures Table 9 lists codes appropriate for these CT scans in the inpatient and outpatient settings. Table 9. CPT and ICD-9-CM Procedure Codes for Bone Densitometry by Computed Tomography CPT/ICD-9-CM Procedure Codes and Descriptions Computed Tomography (CT) 77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g. spine, hips, pelvis) (QCT)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. wrist, radius, heel) (pQCT)

88.98

Bone mineral density studies Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital facilities

Another non-invasive procedure for obtaining bone measurements uses low level ultrasound instead of ionizing radiation. Ultrasound is an imaging technique transmitting sound waves through the peripheral bones (e.g., heel). Applicable codes for bone sonometry in the inpatient and outpatient settings are listed in Table 10. Table 10. CPT and ICD-9-CM Procedure Codes for Bone Sonometry By Ultrasound CPT/HCPCS Codes and Descriptions Ultrasound 76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method (QUS)

CPT category I codes are used by physician offices and hospital outpatient clinics

88.79

Other diagnostic ultrasound

ICD-9-CM Procedure codes are used by hospital facilities

23 II. Diagnostic Tests

Bone Biopsies Another method of obtaining bone measurements involves invasive bone biopsies. A bone biopsy is a surgical procedure where a small sample of bone (usually from the ilium) is removed, generally by a biopsy needle. The biopsy sample is then examined histologically and provides a qualitative measurement of the bone mineral of trabecular bone. Procedures Bone biopsies are usually performed in the hospital setting. CPT and ICD-9-CM procedure codes for bone biopsies from the ilium and other bones are listed in Table 11. Table 11. CPT and ICD-9-CM Procedure Codes for Bone Mass Measurement By Biopsy CPT and ICD-9-CM Procedure Codes and Descriptions 20220

Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs)

20225

Biopsy, bone, trocar, or needle; deep ( e.g., vertebral body, femur)

20240

Biopsy, bone, open; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur).

20245

Biopsy, bone, open; deep ( e.g., humerus, ischium, femur)

38221

Bone marrow; biopsy, needle or trocar

00190

Anesthesia for procedures on facial bones or skull; not otherwise specified

01112

Anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest

01120

Anesthesia for procedures on bony pelvis

01220

Anesthesia for all closed procedures involving upper twothirds of femur

01340

Anesthesia for all closed procedures on lower one-third of femur

01730

Anesthesia for all closed procedures on humerus and elbow

77.41

Biopsy of scapula, clavicle and thorax (ribs and sternum)

77.45

Biopsy of femur

77.49

Biopsy of other bone, except facial bones

44.31

Bone marrow; biopsy

24

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital inpatient facilities

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Laboratory Bone turnover is the initial absorption of bone by osteoclasts followed by deposition of new bone matrix by osteoblasts. Bone turnover, in conjunction with BMD helps to better predict fracture risk than does an assessment with BMD alone. Biochemical markers such as collagen cross links provide a quantitative measurement of bone resorption. Table 12 lists the diagnoses codes covered by Medicare for collagen cross links. Table 12. ICD-9-CM Covered Diagnosis Codes for Collagen Cross Links ICD-9-CM Diagnosis Codes and Descriptions Osteoporosis 242.00-242.91

Thyrotoxicosis

245.2

Chronic lymphocytic thyroiditis (only if thyrotoxic)

246.9

Unspecified disorder of thyroid

252.00-252.02, 252.08

Hyperparathyroidism

256.2

Postablative ovarian failure

256.31-256.39

Other ovarian failure

256.8-256.9

Ovarian dysfunction

268.9

Unspecified vitamin D deficiency

269.3

Mineral deficiency, not elsewhere classified

627.x

Menopausal and postmenopausal disorders

731.0

Osteitis deformans without mention of bone tumor (Paget’s disease of bone)

733.00-733.09

Osteoporosis

733.10-733.19

Pathological fracture

733.90

Disorder of bone and cartilage, unspecified

805.8

Fracture of vertebral column without mention of spiral cord injury, unspecified, closed

V58.65

Long-term (current) use of steroids

V58.69

Long-term (current) use of other medications

Procedure Collagen cross links are reported with CPT code 82523 by physician offices and hospital outpatient clinics.

82523, Collagen cross links, any method (Biochemical markers)

25 II. Diagnostic Tests

Coverage and Payment for Diagnostic Testing: MEDICARE Medicare Coverage In general, the Medicare statute provides coverage only for diagnosis and treatment of an illness, injury or impairment of a body part. However, through a series of legislative changes over the years, the Medicare program now covers a broad range of preventive and screening services such as bone mass measurements. Medicare covers bone density studies performed for the purpose15 of: • identifying bone mass; or • detecting bone loss; or • determining bone quality; or • r easonableness and medical necessity for the evaluation and management of a patient with known or highly suspected osteoporosis. Bone density studies are covered if the patient meets any one of the following five criteria:16 1. A woman who is estrogen-deficient and at clinical risk for osteoporosis, based on medical history and other findings documented in the medical record 2. A patient (male or female) with vertebral abnormalities, as demonstrated by an X-ray to be indicative of osteoporosis, osteopenia or vertebral fracture 3. A  patient (male or female) receiving or expecting to receive more than three months of corticosteroid therapy equivalent to an average of 5.0 mg/day of prednisone17 per day 4. A patient (male or female) with known primary hyperparathyroidism 5. A patient (male or female) being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy Medicare coverage of bone mass measurements includes patients who are on longterm steroid therapy. The minimum dosage requirement is on average, 7.5 mg to 5.0 mg/day of prednisone for at least 3 months. Following an evaluation of the need for a measurement that includes a determination as to the medically appropriate measurement to be used for the individual, the physician or qualified non-physician practitioner treating the physician must: • Provide an order for the test • Supervise the test performance by a qualified supplier or provider

15. The Balanced Budget Act (BBA) of 1997. 16. BBA of 1997; CMS-1321-FC pg 346-383 (2007 MPFS Final Rule, Bone Mass Measurements); Medicare Benefit Policy Manual, Chapter 15, Section 80.5. 17. CMS-1321-FC pg 346-383 (2007 MPFS Final Rule, Bone Mass Measurements); Medicare Benefit Policy Manual, Chapter 15, Section 80.5 26

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• D  etermine the test is reasonable and necessary for diagnosing, treating or monitoring the condition of the patient • Document the physician’s interpretation of the results of the procedure BMD testing is generally covered once every two years (at least 23 months must have passed since the month the last bone mass measurement was performed) unless more frequent bone mass measurements are medically necessary. Physicians determine the medical necessity, subject to Medicare contractor review on a case-by-case basis, of conditions that may warrant more frequent bone mass measurement procedures. Medically necessary indications include, but are not limited to, the following: • M  edical record documentation supporting the rationale that a fracture was caused by bone loss and the reason the patient is at clinical risk for osteoporosis and/or fractures • M  onitoring patients with documented osteoporosis who are being treated with FDA approved drug therapy

– E  strogen therapy (the estrogen must be specifically used for treatment of osteoporosis)



– Alendronate (Fosamax)



– Calcitonin-salmon (Miacalcin-nasal spray or injection)



– Raloxifene (Evista)



– Risedronate (Actonel)



– Teriparatide (Forteo) injection

– Ibandronate (Boniva)

– Zoledronic acid (Reclast)

• T  o determine a patient’s response to pharmacologic therapy when the therapy has been changed to another family of therapeutic agents • M  onitoring patients on long-term glucocorticoid (steroid) therapy of more than three months • A  llowing for confirmatory baseline bone mass measurement (either central or peripheral) to permit future monitoring of a patient, if the initial test was performed with a different technique than the proposed monitoring method. For example, if the initial test was performed using bone sonometry, and monitoring is anticipated using bone densitometry, Medicare will allow coverage of baseline measurement using bone densitometry. Effective for dates of service after January 1, 2007, coverage for confirmatory test is limited to a central (axial) DXA.18 In addition, only central (axial) DXA (CPT 77080) is covered for monitoring osteoporosis drug therapy when reported with the following 18. CMS-1321-FC pg 346-383 (2007 MPFS Final Rule, Bone Mass Measurements); Medicare Benefit Policy Manual, Chapter 15, Section 80.5. 27 II. Diagnostic Tests

ICD-9-CM Diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0.19 Each Part B Carrier, Part A Fiscal Intermediary (FI) or local Medicare Administrative Contractor (MAC) has discretion to interpret the national policy and make it operational at the local level. Carriers, FIs and MACs may vary in the specific ICD-9-CM diagnosis codes and tests that are covered, may have different requirements for medical record documentation (e.g., history and physical, progress notes, flow sheets, test results) and may provide a higher level of clarity on BMD test frequency parameters. Medicare covers BMD tests performed with a bone densitometer or a bone sonometer device that is approved or cleared for marketing by the FDA for bone mass measurement purposes, with the exception of single and dual photon absorptiometry services (e.g. 7835020 and 78351 Bone density (bone mineral content) study, one or more sites; single and dual photon absorptiometry). Medicare coverage for BMD is summarized in Table 13. Table 13. Medicare Coverage of Bone Mass Measurement Methodologies Medicare Coverage Covered 77080

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine)

77081

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)

77082

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment risk

77083

Radiographic absorptiometry (e.g. photodensitometry, radiogrammetry), one or more sites

G0130

Single energy x-ray absorptiometry (SEXA) bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Not Covered 78350

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry (SPA)

78351

Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

Medicare limits coverage of monitoring patients receiving osteoporosis drug therapy, for performing confirmatory baseline test to the DXA of the central (axial) skeleton.21 In addition, BMD services performed for screening purposes or in the 19. CMS Manual System, Pub 100-02, Transmittal 70 Bone Mass Measurements, May 11, 2007. 20. 2007 MPFS Final Rule no longer provides coverage for SPA effective date of service January 1, 2007. 21. .CMS-1321-FC pg 346-383 (2007 MPFS Final Rule, Bone Mass Measurements); Medicare Benefit Policy Manual, Chapter 15, Section 80.5. 28

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absence of associated signs, symptoms, illness or injury will be denied as noncovered. QCT and QUS services follow the same BMD coverage and frequency guidelines described above. Table 14 summarizes Medicare coverage of medically necessary QCT and QUS procedures. Table 14. Medicare Coverage of Bone Mass Measurement Methodologies Medicare Coverage Covered 77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine) (QCT)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel) (QCT)

76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method (QUS)

Medicare does not cover QCT confirmatory baseline testing for monitoring patients receiving osteoporosis drug therapy.22 In addition, services performed for screening purposes or in the absence of associated signs, symptoms, illness or injury will be denied as non-covered. Per the national policy for BMD, a bone biopsy is used to ascertain a differential diagnosis of bone disorders. The qualitative evaluation of bone is covered no more than four times per patient for life, unless there is special justification given. When used more than four times on a patient, bone biopsy leaves a defect in the pelvis and may produce some patient discomfort. Medicare implemented a National Coverage Determination (NCD) for collagen cross links on January 1, 2003. The Medicare NCD for collagen cross links limits testing to those patients for whom there is clinical relevance, such as younger Medicare beneficiaries who are “fast losers” of bone and for those men and women who might become fast losers because of some other therapy such as glucocorticoids. Since the NCD does not explicitly state the frequency parameter for the payment of bio-chemical markers test, payment should be based upon medical necessity. An example of a Medicare covered biochemical marker is the urine marker, N-telopeptide (NTx), a bone resorption marker for osteoporosis, which would be billed to Medicare using CPT code 82523, Collagen cross links, any method. Modifiers Medical necessity for diagnostic testing is determined by physicians and reviewed by payers. In the event a physician expects a payer may not cover a test there are precautions a physician can take, including the introduction of an Advanced 22. CMS-1321-FC pg 346-383 (2007 MPFS Final Rule, Bone Mass Measurements); Medicare Benefit Policy Manual, Chapter 15, Section 80.5 29 II. Diagnostic Tests

Beneficiary Notice (ABN) to the Medicare patient. Additional information on ABNs is included in the “Reimbursement Tools” section of this billing guide. Other payers may use a similar form to inform the patient that a test may not be covered. By attaching an “ABN modifier” to the CPT/HCPCS code, a physician reports to the payer that the beneficiary is aware of potential liability. The modifiers listed in Table 15 are used in such a case. Table 15. Advanced Beneficiary Notice (ABN) Modifiers Modifier and Descriptions

Signed ABN Required

GA

Waiver of liability statement on file

Yes

GX

Service not covered by Medicare

Not necessary

GY

Statutorily excluded

Not necessary

GZ

Expected to be denied as not reasonable and necessary

No – Attach this modifier if an ABN was not signed

CMS developed the “Notice of Exclusion” from Medicare Benefits (NEMB) to assist in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. Use of the NEMB form is optional. Some payers may require modifier-GZ to indicate a signed form is on file. Providers/suppliers may develop their own process to communicate to beneficiaries that they will be billed for non-covered services. There are two components of diagnostic tests: the technical component (performing the actual test) and the professional component which includes physician review and interpretation of the test result. These components can be performed by one or multiple providers and in multiple settings of care. Correct coding allows a provider to report to the payer exactly the component(s) of the test performed using modifiers as shown in Table 16. Table 16. Diagnostic Test Modifiers Modifier and Descriptions

Provider

TC

Technical component only

Hospital facility

26

Professional component only

Physician

No Modifier

Global (G) concept – both technical and professional

Physician

If the physician or independent diagnostic testing facility (IDTF) performs both the technical and professional components using office resources, the physician will bill the appropriate CPT code with no modifier to indicate a global service was performed. If the physician performs only the professional component, the physician will report the CPT code with modifier-26 and report only the professional component. In the hospital outpatient setting, it is understood that the hospital will only provide the technical component of a BMD test, thus no modifier is required, and only the technical component is reported. 30

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Medicare Payment for Physicians and Outpatient Facilities BMD testing will be separately paid when medically necessary under Part B for services performed in the outpatient setting, including the physician office or hospital outpatient department (HOPD). A physician is paid for the global service (G) when performing the procedure entirely in the office setting, using office resources and reporting the service with no modifiers attached. Alternatively, the technical portion (reported with modifier-TC) of a BMD test may be performed in a hospital outpatient setting, while the professional review and interpretation (reported with modifier-26) of the test result is provided by a physician. The technical component accounts for the majority of the cost of the procedure allowing the greater portion of reimbursement going to the technical provider. Medicare payment in the physician office is based on the 2008 Medicare Physician Fee Schedule (MPFS). Medicare payment in the hospital outpatient setting is based on Ambulatory Payment Classification (APC) rates found in Addendum B of the 2008 Outpatient Prospective Payment System (OPPS) where CPT and HCPCS codes are grouped into APCs based on the resources used for a particular type of service. The Medicare deductible applies to BMD testing and a beneficiary will be responsible for 20 percent (co-insurance) of the Medicare-approved amount after the yearly Part B deductible is met. Unlike drug reimbursement methodology, Medicare does not require a physician accept assignment for BMD testing claims. In Table 17 we indicate the 2008 national average Medicare allowed amounts and payment status indicators (SI) for BMD testing in both the physician and hospital outpatient settings.

31 II. Diagnostic Tests

Table 17. 2008 Medicare National Average Rates 2008 Medicare National Average Rates CPT/HCPCS Code and Description

Physician Rate23 (SI24)

HOPD APC Rate25 (SI26)

(A) (A) (A)

0288 $72.51

(S)

77080

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine)

-G -TC -26

77081

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)

-G $34.28 -TC $23.99 -26 $10.28

(A) (A) (A)

0665 $32.40

(S)

77082

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment

-G $33.14 -TC $25.14 -26 $8.00

(A) (A) (A)

0260 $44.29

(X)

77083

Radiographic absorptiometry (e.g. photodensitometry, radiogrammetry), 1 or more sites

-G $31.61 -TC $22.09 -26 $9.52

(A) (A) (A)

0261 $73.69

(X)

G0130

Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

-G $36.94 -TC $26.66 -26 $10.28

(A) (A) (A)

0260 $44.29

(X)

78350

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry (SPA)

N/A

(N)

N/A

(E)

$95.60 $85.31 $10.28

23 24 25 26

G = Global (Professional and technical component); TC = Technical component; 26 = Professional component

Hospitals must report HCPCS codes for bone mass measurements under Revenue Code 320 Radiology-Diagnostic with number of units and line item dates of service per revenue code line for each bone mass measurement reported. QCT and QUS will be separately paid when medically necessary under Part B for services performed in the outpatient setting, including the physician office or hospital outpatient department (HOPD). A physician is paid for the global service (G) when performing the procedure entirely in the office setting, using office resources and reporting the service with no modifiers attached. Alternatively, the technical portion (reported with modifier-TC) of the procedure may be performed in a hospital outpatient setting, while the professional review and interpretation (reported with modifier-26) of the test result are provided by a physician. The technical component accounts for the majority of the cost of the procedure allowing the greater portion of reimbursement going to the technical provider. 23. Medicare national average rate 2008 MPFS PPRVU 24. MPFS Status Code (SI): A = Active, Separately paid if covered; N = Non covered 25. Medicare national average rate from 2008 OPPS Addendum B 26. OPPS Status Indicator (SI): S= Significant procedure, Not discounted when multiple, Paid under OPPS, Separate APC payment; X =Ancillary services, Paid under OPPS, Separate APC payment; E = Not paid under OPPS or any other Medicare payment system 32

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Table 18 includes the 2008 national average Medicare allowed amounts and payment status indicators (SI) for QCT and QUS procedures in both the physician and hospital outpatient settings. Table 18. 2008 Medicare National Average Rates

27 28 29 30

2008 Medicare National Average Rates CPT/HCPCS Code and Description

Physician Rate

HOPD

Code

Description

Rate27 (SI28)

APC Rate29 (SI30)

77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine) (QCT)

-G -TC -26

$162.63 $150.82 $11.81

(A) (A) (A)

0288

$72.51

(S)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel) (QCT)

-G -TC -26

$82.65 $72.37 $10.28

(A) (A) (A)

0282 $100.88

(S)

76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method (QUS)

-G -TC -26

$22.09 $19.42 $2.67

(A) (A) (A)

0340

(X)

$40.19

G = Global (Professional and technical component); TC = Technical component; 26 = Professional component

Table 19 includes the 2008 national average Medicare allowed amounts and payment status indicators (SI) for bone biopsies in both the physician and hospital outpatient settings. When multiple bone biopsies are performed, Medicare will reduce the payment for the additional procedures by 50 percent.

27. Medicare national average rate 2008 MPFS PPRVU 28. MPFS Status Code (SI): A = Active, Separately paid if covered 29. Medicare national average rate from 2008 OPPS Addendum B 30. OPPS Status Indicator (SI): S= Significant procedure, Not discounted when multiple, Paid under OPPS, Separate APC payment; X =Ancillary services, Paid under OPPS, Separate APC payment 33 II. Diagnostic Tests

Table 19. 2008 Medicare National Average Rates for Bone Biopsies

31

32

33

34

2008 Medicare National Average Rates CPT/HCPCS Code and Description

Physician

HOPD

Code

Description

Rate31 and (SC32)

APC Rate33/(SI34)

20220

Biopsy, bone, trocar, or needle; superficial ( e.g., ilium, sternum, spinous process, ribs)

$183.96

(A)

0020

$553.18

(T)

20225

Biopsy, bone, trocar, or needle; deep ( e.g., vertebral body, femur)

$765.55

(A)

0020

$553.18

(T)

20240

Biopsy, bone, open; superficial ( e.g., ilium, sternum, spinous process, ribs, trochanter of femur)

$212.91

(A)

0020 $1,344.57

(T)

20245

Biopsy, bone, open; deep ( e.g., humerus, ischium, femur)

$578.54

(A)

0020 $1,344.57

(T)

T = Significant procedure; Multiple reduction applies. Paid under OPPS; separate payment under APC

Reimbursement for a collagen cross links test is based on the Medicare Clinical Laboratory Fee Schedule for testing performed both in physician offices and in hospital outpatient facilities. The Medicare national payment limit is listed in Table 20. Table 20. 2008 Medicare National Limit in Physician Office and Hospital Outpatient Facilities

35

36

37

38

2008 Medicare National Average Rates CPT/HCPCS Code and Description

Physician

HOPD

Code

Description

Rate35 and (SC36)

Rate37and (SI38)

82523

Collagen cross links, any method (Biochemical markers)

$26.11

$26.11



(X)

(Paid on Clinical Lab Fee Schedule)

(A)

(Paid on Clinical Lab Fee Schedule)

.31. Medicare national average rate 2008 MPFS PPRVU

32. Status Code (SC): A = Active; X =Statutory exclusion, Not paid under the MPFS; Paid under other fee schedule.

33. Medicare national average rate from 2008 OPPS Addendum B.

34. Status Indicator (SI): T= Significant procedure, Multiple reduction applies, Paid under OPPS, Separate APC payment; A=Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS.

35. Medicare national average rate 2008 MPFS PPRVU.

36. Status Code (SC): A = Active; X =Statutory exclusion, Not paid under the MPFS; Paid under other fee schedule.

37. Medicare national average rate from 2008 OPPS Addendum B.

38. Status Indicator (SI): T= Significant procedure, Multiple reduction applies, Paid under OPPS, Separate APC payment; A=Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS.

34

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Medicare Payment for Inpatient Services The primary Medicare Severity Diagnosis Related Group (MS-DRG) defines the payment rate for an inpatient stay. DRGs are not reported on a CMS-1450 hospital claim form. Rather, hospital billing systems internally crosswalk the ICD-9-CM diagnosis codes to primary and secondary MS-DRGs. MS-DRGs are structured into three levels of severity: major complications or comorbidities (MCCs), complications or comorbidities (CC) and non-CCs.39 Table 21 includes a list of ICD9-CM diagnosis codes that may be applicable to a patient with a osteoporosisrelated condition, the associated MS-DRGs and the 2008 average Medicare payment rates for these MS-DRGs.4041 Table 21. ICD-9-CM and MS-DRG Crosswalk ICD-9-CM Diagnosis to DRG Codes with Descriptions Osteoporosis

MS-DRG40

268.2

Osteomalacia

733.00

Unspecified osteoporosis

733.01

Senile osteoporosis (Postmenopausal)

733.02

Idiopathic osteoporosis

733.03

Disuse osteoporosis

733.09

Other osteoporosis (drug-induced)

V17.81

Family history of osteoporosis

Rate41

553 Bone Diseases and Specific Arthropathies with MCC

$4,501.00

554 Bone Diseases and Specific Arthropathies without MCC

$3,168.22

951 Other Factors Influencing Health Status

$2,989.13

39. 24th Edition, DRG Expert, Ingenix 2008 40. Ibid. 41. Medicare national average payment, DRG Expert, Ingenix 2008

35 II. Diagnostic Tests

Table 21. ICD-9-CM and MS-DRG Crosswalk (continued) ICD-9-CM Diagnosis to DRG Codes with Descriptions 733.90

Disorder of bone and cartilage, unspecified

793.7

Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture 733.10

Pathologic fracture, unspecified site

733.11

Pathologic fracture of humerus

733.12

Pathologic fracture of distal radius and ulna (Wrist NOS)

733.13

Pathologic fracture of vertebrae (Collapse of vertebrae)

733.14

Pathologic fracture of neck of femur (Femur/Hip NOS)

733.15

Pathologic fracture of other specified part of femur

733.16

Pathologic fracture of tibia and fibula (Ankle NOS)

733.19

Pathologic fracture of other specified site

V54.20-V54.29

Aftercare for healing pathologic fracture (Site specific)

Fracture of Neck and Trunk 805.00-829.1

Fracture of Neck and Trunk (site specific)

Diseases of Endocrine Glands 252.0x

Hyperparathyroidism

255.0

Cushing’s syndrome

36

564 Other Musculoskeletal System and Connective Tissue Diagnoses w MCC

$5,678.82

565 Other Musculoskeletal System and Connective Tissue Diagnoses w CC

$4,405.17

566 Other Musculoskeletal System and Connective Tissue Diagnoses w/o CC/MCC

$3,611.65

MS-DRG

Rate

542 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy w MCC

$7,279.32

543 Pathological Fractures and Musculoskeletal and Connective Tissue Malignant w CC

$5,456.18

544 Pathological Fractures and Musculoskeletal and Connective Tissue Malignant w/o CC/MCC

$4,596.97

559 Aftercare, Musculoskeletal System and Connective Tissue w MCC

$5,922.49

560 Aftercare, Musculoskeletal Sys and Connective Tissue w CC

$4,169.33

561 Aftercare, Musculoskeletal Sys and Connective Tissue w/o CC/MCC

$3,304.24

MS-DRG

Rate

Varies depending on the resources used to treat the fracture

MS-DRG

Rate

643 Endocrine Disorders with MCC

$6813.99

644 Endocrine Disorders with CC

$5,205.17

645 Endocrine Disorders without CC/MCC

$4,066.08

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Table 21. ICD-9-CM and MS-DRG Crosswalk (continued) ICD-9-CM Diagnosis to DRG Codes with Descriptions 256.2

Postablative ovarian failure

256.31

Premature menopause (permanent cessation of ovarian function)

256.39

Other ovarian failure

627.x

Menopausal and postmenopausal disorders

268.9

Unspecified vitamin D deficiency

V07.4

Hormone replacement therapy (postmenopausal)

V49.81

Asymptomatic postmenopausal status (age-related) (natural)

742 Uterine and Adnexa Proc for Non-malignancy with CC/ MCC

$6,078.08

743 Uterine and Adnexa Proc for Non-malignancy w/o CC/MCC

$4,243.21

760 Menstrual and Other Female Reproductive System Disorders w CC/MCC

$3,381.06

761 Menstrual and Other Female Reproductive System Disorders w CC/MCC

$2,724.91

640 Nutritional & Misc Metabolic Disorders w MCC

$4,791.71

641 Nutritional & Misc Metabolic Disorders w/o MCC

$3,546.45

951 Other Factors Influencing Health Status

$2,989.13

coverage and payment for diagnostic testing: MEDICAID Medicaid Coverage for Physicians and Facilities Coverage guidelines specific to diagnostic testing vary by state. Coverage for physician services is a mandatory component of all Medicaid programs. All states provide coverage for medically necessary care; this coverage is typically provided with little or no out-of-pocket expense for the patient. Coverage for services rendered in laboratory facilities is similar to those in a hospital outpatient setting. Medicaid coverage for inpatient services varies from state to state. Some states may limit the patient benefits by limiting the number of inpatient hospital days covered or by setting a cap on the dollar amount that will be paid per fiscal year. It is important to check coverage details with each state Medicaid agency. Medicaid Payment for Physicians and Facilities State Medicaid programs have adopted fee-schedule mechanisms to reimburse for physician services. Actual payment amounts vary, and Medicaid payment levels are typically below the Medicare fee schedule amount. Reimbursement methodologies for hospital outpatient services provided to Medicaid patients vary from state to state. Most states use either a modified version of the Medicare APC system, fee schedules, or predetermined case rates. 37 II. Diagnostic Tests

Reimbursement for services rendered in the laboratory facilities is similar to those in a hospital outpatient setting. Medicaid payment for inpatient services also varies by state. Most Medicaid programs reimburse hospital inpatient services based on a modified version of the Medicare DRG system or case rates. Payment may also be based on a per diem or capitated system. It is important to contact a local Medicaid agency for specific reimbursement rates for bone density tests and vertebral fracture risk assessments.

coverage and payment for diagnostic testing: PRIVATE PAYER Private Payer Coverage for Physicians and Facilities Coverage guidelines specific to diagnostic testing vary by payer and plan type. Physician office services are a standard, covered benefit for most private payers. Both indemnity and managed-care plans have varying network or coverage restrictions for physician services. Primary care physicians often preauthorize the need for services by specialists. Patient coinsurance and deductible requirements can vary dramatically by plan. Additionally, managed care plans may restrict patient access to certain physicians by using provider networks. Private payers typically cover hospital outpatient services that are considered medically necessary. Coverage for services rendered in the laboratory facilities is similar to those in a hospital outpatient setting. Private payers vary in how they cover hospital inpatient services. Providers should contact each individual payer directly for specific coverage of bone density tests and vertebral fracture risk assessments. Private Payer Payment for Physicians and Facilities Payment mechanisms vary significantly by payer and site of service. Private health plans (including managed care plans) use a variety of means to reimburse for diagnostic testing provided in the physician office setting. Physician reimbursement systems vary with physician contracting and plan-specific fee schedules. Payers may base their payment rates on fee schedules (similar to the Medicare fee schedule), UCR, or a percentage of the provider’s charge. Health Maintenance Organization (HMO) plans may use capitation fees by paying the physician a fixed fee per eligible health plan member per month. Indemnity plans most commonly pay a percentage of allowed charges, typically 80 percent with the patient being responsible for the remainder. Reimbursement for any medical and surgical supplies used in the physician office setting is typically included in the payment for the billed procedure. Private payers vary in how they reimburse hospital outpatient and hospital inpatient services and payment levels are based on contractual agreements between the payer and healthcare provider.

38

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­­­Section 3 Most public and private insurers cover injectable drugs administered in outpatient settings under medical, rather than pharmacy benefits. These are the same benefits that apply when patients see a physician for a sick office visit, or when they undergo outpatient surgery in a hospital-based facility.

PhysicianAdministered Drugs

ICD-9-CM Diagnosis Codes ICD-9-CM diagnosis codes help establish the need for services related to the treatment of osteoporosis and demonstrate the medical necessity for administering certain injectable and intravenous therapies. The following table shows ICD-9-CM diagnosis codes that may be appropriate for physicians and facilities to report for patients with osteoporosis. Table 22. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Conditions ICD-9-CM Diagnosis Codes and Descriptions Osteoporosis 733.00

Unspecified osteoporosis

733.01

Senile osteoporosis (Postmenopausal)

733.02

Idiopathic osteoporosis

733.03

Disuse osteoporosis

733.09

Other osteoporosis (drug-induced)

V17.81

Family history of, Osteoporosis

733.90

Disorder of bone and cartilage, unspecified

793.7

Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture 733.10

Pathologic fracture, unspecified site

733.11

Pathologic fracture of humerus

733.12

Pathologic fracture of distal radius and ulna (Wrist NOS)

733.13

Pathologic fracture of vertebrae (Collapse of vertebrae)

733.14

Pathologic fracture of neck of femur (Femur/Hip NOS)

733.15

Pathologic fracture of other specified part of femur

733.16

Pathologic fracture of tibia and fibula (Ankle NOS)

733.19

Pathologic fracture of other specified site

V54.20-V54.29

Aftercare for healing pathologic fracture (Site specific)

Fracture of Neck and Trunk 805.00-829.1

Fracture of Neck and Trunk (site specific)

39 III. Physician Administered Drugs

Table 22. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Conditions (continued) ICD-9-CM Diagnosis Codes and Descriptions Diseases of Endocrine Glands 252.0x

Hyperparathyroidism

255.0

Cushing’s syndrome

256.2

Postablative ovarian failure

256.31

Premature menopause (permanent cessation of ovarian function)

256.39

Other ovarian failure

259.3

Ectopic hormone secretion, not elsewhere classified (hyperparathyroidism)

268.2

Osteomalacia

268.9

Unspecified vitamin D deficiency

627.x

Menopausal and postmenopausal disorders

V07.4

Hormone replacement therapy (postmenopausal)

V49.81

Asymptomatic postmenopausal status (age-related) (natural)

HCPCS Coding for Physician-Administered Drugs The Healthcare Common Procedure Coding System (HCPCS) is used to report specific equipment, services, supplies and certain drugs, including physicianadministered drugs. HCPCS level II drug codes are commonly referred to as “J-codes.” These codes are typically used to report the administration of certain injectable and intravenous drugs in outpatient settings including physician offices and hospital outpatient departments, as well as in hospital inpatient settings. Sample HCPCS codes applicable to physician-administered drugs that are approved for treatment of patients with osteoporosis are listed in the table below. Table 23. HCPCS Coding for Physician-Administered Drugs for Osteoporosis

42

Brand name

Description40

Route of Administration

HCPCS code

Boniva

Injection, ibandronate sodium, 1mg

IV, 3mg every 3 months

J1740

Miacalcin

Injection, calcitonin-salmon, up to 400 units

IM or SC, 100 units, every other day

J0630

Reclast®

Injection, zoledronic acid, 1mg

IV, once a year

J3488

® ®

42. HCPCS Level II 2008 Expert, Ingenix 2007. 40

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National Drug Code (NDC) Some public or private payers that cover and reimburse physician-administered drugs may require providers to report National Drug Codes (NDCs) on claim forms to provide more detail on the specific drugs administered. Certain payers require providers to include NDC numbers in an 11-digit format. All numbers, including zeroes, should be included on the claim form when documenting NDC information as part of claims submission. The following are examples of NDCs for drugs approved for treatment of osteoporosis. Table 24. National Drug Codes for Physician-Administered Drugs for Osteoporosis 10-Digit Format Boniva® Calcimar® Reclast®

0004-0188-09 0078-0149-23 0078-0435-61

11-Digit Format Boniva® Calcimar® Reclast®

00040-0188-09 00780-0149-23 00078-0435-61

Coding for Drug Administration Procedure codes are essential for proper claims processing because they identify the services performed for a patient. Below is a sample list of CPT procedure codes that may be used to report the administration of injectable or infused medications to patients in physician offices or hospital outpatient departments. Table 25. CPT Drug Administration Coding CPT® Code

Description

90765

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

90772

Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

90774

Intravenous push, single or initial substance/drug

90779

Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion

Health care providers may also report evaluation and management codes in some circumstances when an office visit service is performed that is separately identifiable from a drug administration service. The following CPT procedure codes may be used to report such E/M services.

41 III. Physician Administered Drugs

Table 26. CPT Evaluation and Management (Office Visit) Codes CPT® Code

Description

New Patient

99201

Office or other outpatient visit; problem-focused history

99202

Office or other outpatient visit; expanded problem-focused history

99203

Office or other outpatient visit; detailed history

99204

Office or other outpatient visit; comprehensive history - 45 minutes

99205

Office or other outpatient visit; comprehensive history - 60 minutes

Established Patient

99211

Office or other outpatient visit; 5 minutes

99212

Office or other outpatient visit; problem-focused history

99213

Office or other outpatient visit; expanded problem-focused history

99214

Office or other outpatient visit; detailed history

99215

Office or other outpatient visit; comprehensive history

Some payers do not reimburse for a drug administration procedure and an evaluation and management code reported on the same date of service. For example, Medicare will not allow CPT code 99211 to be billed on the same date of service as a drug administration code. Some payers require providers to use a modifier to demonstrate that the E/M procedure was a separate service from other services rendered on the same date: -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. REVENUE CODES Revenue codes are three-digit numeric codes developed by the American Hospital Association (AHA). They describe and group hospital charges by cost center. The following table gives examples of revenue codes that may be appropriate for drugs used to treat osteoporosis in hospital inpatient or outpatient settings. Table 27. Revenue Codes for Drugs Used to Treat Osteoporosis in the Hospital Setting

42

Revenue Code

Description

025X

Pharmacy

026X

IV Therapy

0636

Drugs requiring detailed coding

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Medicare Coverage for Physicians and Facilities Medicare typically covers injectable and intravenous drugs used under the following conditions: •

Approved by the Food and Drug Administration (FDA)

•

Administered incident to a physician’s service

•

Used for a medically necessary purpose

It is important to check with your local Medicare carriers, contractors or fiscal intermediaries (FIs) regarding specific coverage or documentation requirements for physician-administered drugs. Medicare employs three methods of developing coverage policies for physicianadministered injectable and intravenous drugs. These methods include National Coverage Determinations (NCDs), local coverage determinations (LCDs) and caseby-case review. NCDs may be issued by CMS for a specific product, therapy or device. When implemented, they become binding to all Medicare contractors, including local carriers and FIs. In the absence of a NCD, LCDs may be developed by individual carriers and FIs to provide guidance to the medical community regarding the reasonableness and necessity of a product, conditions under which the product is covered and direction regarding coding for the product. Payment for Physicians and Facilities Medicare reimburses physicians for the professional services they provide to patients such as drug administration and E/M. Medicare requires that any E/M service be separate and identifiable from the drug administration. The additional service must be documented in the patient’s medical record to bill for both services. Physician Fee Schedule Medicare reimburses physicians for professional services they provide to patients in the physician office based on the Physician Fee Schedule, which is updated annually. Services that are associated with the administration of a product or biologic are covered and reimbursed according to set payment rates associated with specific HCPCS and CPT codes. The payment rates are adjusted by geographic region, so there will be some variations depending on where in the country you are located. On the next page are the 2008 national average payment rates for sample services covered under the Medicare Physician Fee Schedule.

43 III. Physician Administered Drugs

Table 28. Coding and Medicare Payment for Physician Office Services

43

2008 Medicare National Average Payment43

Code

Description

90765

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

$ 73.89

90772

Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

$ 20.57

90774

Intravenous push, single or initial substance/drug

$ 57.89

90779

Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion

By-report procedure, determined on case-bycase basis.

99201

Office or other outpatient visit for the evaluation and management of a new patient (Level 1)

$ 36.18

99202

Office or other outpatient visit for the evaluation and management of a new patient (Level 2)

$ 62.08

99203

Office or other outpatient visit for the evaluation and management of a new patient (Level 3)

$ 91.03

99204

Office or other outpatient visit for the evaluation and management of a new patient (Level 4)

$ 138.64

99205

Office or other outpatient visit for the evaluation and management of a new patient (Level 5)

$ 174.06

99211

Office or other outpatient visit for the evaluation and management of an established patient (Level 1)

$ 19.81

99212

Office or other outpatient visit for the evaluation and management of an established patient (Level 2)

$ 37.33

99213

Office or other outpatient visit for the evaluation and management of an established patient (Level 3)

$ 59.80

99214

Office or other outpatient visit for the evaluation and management of an established patient (Level 4)

$ 89.89

99215

Office or other outpatient visit for the evaluation and management of an established patient (Level 5)

$ 121.50

44

43. Centers for Medicare & Medicaid Services (CMS). 2008 National Physician Fee Schedule Relative Value File. Revised January 3, 2008. Non-Facility Transitional Allowable with 1.8806 budget neutrality factor to Work RVU.

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Hospital Outpatient Prospective Payment System Medicare Part B reimburses hospital outpatient facilities based on the hospital Outpatient Prospective Payment System (OPPS), under which services that are comparable clinically and in resource utilization are grouped together into Ambulatory Payment Classifications (APCs). The following table describes codes associated with the administration of certain injectable and intravenous drugs in the hospital outpatient setting, the APCs to which these codes map and their 2008 average national payment rates. Table 29. Coding and Medicare Payment for Hospital Outpatient Services Code

Maps to APC

Description

2008 Medicare National Average Payment44

90765

0440

Level V Drug Administration

$114.64

90772

0437

Level II Drug Administration

$25.13

90774

0438

Level III Drug Administration

$51.22

90779

0436

Level I Drug Administration

$16.21

99201

0604

Office/outpatient visit, new

$53.43

99202

0605

Office/outpatient visit, new

$63.46

99203

0607

Office/outpatient visit, new

$84.24

99204

0608

Office/outpatient visit, new

$105.76

99205

0609

Office/outpatient visit, new

$138.47

99211

0604

Office/outpatient visit, est

$53.43

99212

0605

Office/outpatient visit, est

$63.46

99213

0605

Office/outpatient visit, est

$63.46

99214

0606

Office/outpatient visit, est

$84.24

99215

0607

Office/outpatient visit, est

$105.76

44

Reimbursement for Physician-Administered Drugs Medicare may offer separate reimbursement for certain physician-administered injectable and intravenous drugs when they are given in the physician office. Also, certain drugs known as Specified Covered Outpatient Drugs (SCODs) are separately payable by Medicare in the hospital outpatient setting, including those with transitional pass-through status, which is assigned by CMS, or those whose median cost is greater than $60. Medicare reimburses physician-administered drugs given in physician offices based on 106 percent of average sales price (ASP). Medicare reimburses most physician-administered drugs, SCODs, given in the hospital outpatient departments 44. Medicare national average rate from 2008 OPPS Addendum B. 45 III. Physician Administered Drugs

based on 105 percent of average sales price (ASP). The ASP is the average sales price from a manufacturer to all purchasing entities who obtain the product from the manufacturer (such as wholesalers and distributors). Every quarter, manufacturers submit sales data to CMS to calculate a product’s ASP. ASP payment files issued by CMS each quarter include historical ASP data. There is a two quarter lag between when manufacturers report actual ASP data to CMS and when CMS uses that data to establish the payment rate. In cases where CMS has not yet published the ASP for a given drug – such as when newer drugs hit the market – reimbursement is based instead on the drug’s wholesale acquisition cost (WAC), as published in pricing compendia such as RedBookTM, plus 5 percent (manufacturer did not submit a pass-through application) or 6 percent (manufacturer did submit a pass-through application). Medicare does not offer separate payment for injectable and intravenous drugs administered by physicians in hospital inpatient settings. Reimbursement for physician-administered drugs in the inpatient setting continues to be bundled under the Medicare Severity Diagnosis Related Group (MS-DRG) system, in which a single payment is assigned based on a patient’s primary diagnosis and cost of resources typical for treatment. Medicaid Most physician-administered injectable and intravenous drugs are covered under state Medicaid programs. Coverage policies and reimbursement for drugs and their associated services often vary widely from state to state. Most Medicaid programs use a fee schedule to reimburse physicians and outpatient facilities for the administration services associated with physician-administered drugs. Additionally, state Medicaid programs typically reimburse drugs separately from administration service using a variety of methodologies including: • A percentage of Average Wholesale Price (AWP) • A percentage of Wholesale Acquisition Cost (WAC) • A percentage of Average Sales Price (ASP) • Acquisition/Invoice cost It is important to check with your state Medicaid agency for actual reimbursement methodologies, payment amounts and claim submission requirements. Private Insurance Medical services rendered in a physician office or hospital outpatient department are generally covered by most private plans, although network or coverage restrictions vary. Most private payers will also cover injectable and intravenous drugs administered in these settings. Reimbursement methodologies vary dramatically by payer, plan type and contract provisions between networks and physicians, and network and hospital facilities. 46

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Private payers typically reimburse physician services based on a fee schedule. They may reimburse physician-administered injectable drugs separately through means such as: • A percentage of Average Wholesale Price (AWP) • A percentage of Wholesale Acquisition Cost (WAC) • A percentage of Average Sales Price (ASP) • Acquisition/Invoice Cost It is important to review contracts and contact local payers directly to determine patient-specific benefits, payment policies and procedures. You may also contact the payer directly to understand exact coding and coverage requirements, such as the need for prior authorizations or documentation of medical necessity. Additional information on prior authorization is included in the “Reimbursement Tools” section of this billing guide.

47 III. Physician Administered Drugs

Notes

48

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­­­Section 4 Coverage for oral prescription drugs and self-injectable therapies varies considerably among different types of insurance plans. Unlike physician-administered therapies, oral and self-administered therapies are typically covered under a prescription or pharmacy benefit. Your patient may pay a fixed amount based on where the drug falls on the plan’s drug formulary. It is important that you or assigned office staff understand the coverage and benefits offered by the patient’s specific health plan to ensure that the patient fully understands the cost associated with access to the prescribed therapy.

­­­ Oral and SelfAdministered Therapies

Oral Therapies for Osteoporosis The following table provides a list of oral and self-administered therapies you may prescribe for your patients to aid in the prevention or treatment of osteoporosis. Table 30. Oral/Self-Administered Medications to Prevent and Treat Osteoporosis Drug

Brand name

Route of Administration

Alendronate

Fosamax® or Fosamax® plus D

Oral

Ibandronate

Boniva®

Oral

Risedronate

Actonel® or Actonel® with Calcium

Oral

Calcitonin

Miacalcin®, Calcimar® or Fortical®

Self-Injected or Nasal Spray

Estrogen Therapy (ET)

Climara®, Estrace®, Estraderm®, Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle®)

Patch or Oral

Hormone Therapy (HT)

Activella™, Femhrt®, Premphase®, Prempro®

Oral

Parathyroid hormone [PTH(1-34), teriparatide]

Forteo®

Self-Injected

Raloxifene

Evista®

Oral

National Drug Codes for Oral and Self-Administered Drugs The National Drug Code (NDC) system is used as a universal product identifier for drugs. The U.S. Food and Drug Administration (FDA) assigns each drug product listed under Section 510 of the Food, Drug and Cosmetic Act a unique number called the NDC that identifies the drug manufacturer or distributor, drug strength, dosage or formulation and package size. Retail pharmacies primarily use NDCs for billing and reimbursement purposes. When pharmacies or a physician office licensed to dispense drugs submits a drug 49 IV. ORAL AND SELF-ADMINISTERED THERAPIES

claim, the NDC needs to be in a standard 5-4-2 (11-digit) format. The assigned NDC from the FDA is typically a 10 digit NDC and can be formatted in various configurations. The table below describes common formatting of the 10 digit NDC configuration and how the NDC can be converted into the required 5-4-2 (11 digit) format. Product specific NDCs are published by major drug pricing compendia such as Red Book and First Databank. 10 Digit Configuration

Leading Zero Placement for 11 Digit 5-4-2 Configuration

XXXX-XXXX-XX 4-4-2

0XXXX-XXXX-XX 5-4-2

XXXXX-XXX-XX5-3-2

XXXXX-0XXX-XX 5-4-2

XXXXX-XXXX-X 5-4-1

XXXXX-XXXX-0X 5-4-2

Payment for Oral and Self-Administered Therapies Payment for the dispensing of oral and self-administered drugs is typically made directly to the dispensing retail or specialty pharmacy. Practically all payer types, including Medicare and Medicaid, process and provide payment to network or contracting pharmacies. For private commercial payers, the payment amount for oral and self-administered therapies is typically based on contracted negotiated rates between the insurance company and the dispensing pharmacy. Almost all prescription drug plans, regardless of payer type, have an associated patient out-of-pocket requirement for covered oral and self-administered drugs. The patient share of prescription cost could be in the form of a fixed dollar or variable percentage amount. For example, in a typical three-tier pharmacy benefit, the patient may be responsible for a $20 co-pay for generic drugs; $35 co-pay for preferred brand drugs and $50 for non-preferred brand drugs. A patient could be responsible for 25% of the cost for the dispensed drug. If the pharmacies negotiated payment rate for the dispensed drug is $100, in this scenario, the patient would be responsible for $25 (25% of $100). The dispensing pharmacy is responsible for collecting applicable patient cost-share amounts for oral and self-administered drugs covered under a typical pharmacy benefit. Total payment to the dispensing pharmacy would be payment from the insurance company and any applicable patient cost share amount.

Understanding Common Prescription Benefit Structures Many patients have access to prescription drug coverage through private insurance. The patient’s employer may offer one prescription drug benefit option as part of their employee benefits package. Patients with Medicare and Medicaid also 50

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have several options regarding prescription drug coverage. Whether your patient’s prescription benefit is through a private commercial or public insurance plan, the benefit will most likely feature formularies, prior authorizations (PA) requirements, step-therapy requirements and quantity limits. Additional information on prior authorization is included in the “Reimbursement Tools” section of this billing guide. Formularies A drug formulary is a listing of drug therapies a particular insurance plan has chosen to cover. There are three basic types of drug formularies. • O  pen drug formulary: All prescription drugs are covered, with few exceptions. Lower patient co-pay for generics and higher co-pay for brand drugs are common in open formularies. • C  losed drug formulary: All drugs on the formulary are covered (patient pays a co-pay). For drugs not on the list, patient must pay full cash (retail) price of the drug. • T  iered drug formulary: Preferred (on the formulary) generic drugs are at the lowest co-pay, preferred (on the formulary) brand name drugs at the next co-pay level. All drugs not on the preferred list are subjected to a higher tier of co-payment and may be subject to prior authorization or other utilization control mechanisms. For drugs not on the list, patient must pay full cash (retail) price. Patient and provider access to an insurance company’s drug formulary is typically available via the insurance company’s website. Pharmacies also have access to formularies for the plans they are contracted with as network pharmacies. Contacting the payer or the patient’s pharmacy could assist in proactively determining a product’s specific formulary/coverage status for the patient’s prescription drug plan. Drug Utilization Mechanisms There are several ways an insurance company can assure medications are being prescribed appropriately. The three most common methods used are: • P  rior authorization: The insurance plan or benefit sponsor must approve the drug before a patient has access. Physicians or pharmacists must submit clinically relevant documentation on why a patient needs a particular medication. • Q  uantity Limits: Controls in the amount of pills dispensed per prescription also occur in the pharmacy benefit. Several drugs have limits to how many days they can be used according to the clinical studies that allowed the drug to be FDA-approved. For example, osteoporosis therapies with added calcium may have quantity limit restrictions as opposed to therapies not supplemented with calcium.

IV. ORAL AND SELF-ADMINISTERED THERAPIES

51

• Step-Therapy: Before a patient can be prescribed and have pharmacy coverage for a particular drug, he/she must have tried and failed a particular therapy before trying the “next step up” in therapy. Step therapy requirements for osteoporosis treatments will vary by payer and prescription plan. If step-therapy is a requirement for a particular treatment, details on what the patient has previously been prescribed should be provided by the payer. Medicare Prescription Drug Benefit As with other types of prescription drug coverage, Part D plans are structured such that beneficiaries incur certain out-of-pocket expenses for their covered prescription medications. The amount of out-of-pocket expense is different for the various plan types and medications. With a wide range of plan options available, it is important for both beneficiaries and prescribing physicians to understand the specific plan benefit requirements regarding drug formulary status and out-of-pocket costs, as well as available Part D resources. Requesting Part D Formulary and Tiering Exceptions Like most prescription drug plans, Medicare Part D plans have formularies. If a physician needs to prescribe a drug that isn’t on the Medicare drug plan’s formulary, the enrollee or the enrollee’s prescribing physician can request an exception from the plan. An exception request is a kind of coverage determination. A coverage determination is the first decision a plan makes about the benefits an enrollee is entitled to receive. The first step in requesting an exception is to contact the drug plan. The plan will advise how to submit the request and the information they need to make a decision. The enrollee’s doctor must submit a statement supporting the request. The doctor’s statement must demonstrate that the requested drug is “medically necessary” for treating the person’s condition. Once this information is submitted, a plan must inform the enrollee and the prescribing physician, if appropriate, of its decision on an exceptions request as expeditiously as the enrollee’s health condition requires, but no later than 24 hours after receipt of an expedited request and no later than 72 hours after receipt of a standard request. The clock starts running after the plan has the exception request and the doctor’s supporting statement. Medicaid Prescription Drug Coverage As with other prescription drug plans, state Medicaid agencies use a variety of utilization mechanisms to manage access to oral and self-administered therapies. Medicaid Prescription Drug Coverage Drug Utilization Restrictions Like other prescription drug plans, Medicaid programs may require prior authorization, diagnosis, quantity or step-therapy restrictions for some oral and self-administered therapies. The rules and processes for obtaining or meeting the drug utilization requirements vary from state to state and the drug therapy being prescribed. 52

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Preferred Drug Lists (PDLs) A PDL is a list of preferred drugs that have been reviewed by a committee and are the Medicaid program’s recommended first choice therapies. Not all states use a PDL; however for those states that do, having access to the state’s current PDL can be useful in assessing the potential requirement for prior authorization. Inclusion or exclusion of a drug from a PDL does not always indicate the drug is covered or non-covered by the program. Some drugs included on a PDL will require prior authorization and drugs not on the PDL could be covered pending approval through some form of drug utilization, such as prior authorization. States that use a PDL typically provide public access to the PDL via their state Medicaid websites. Prior Authorization Requirements State Medicaid prior authorization (PA) processes vary from state to state. In some cases, the pharmacy filing the claim can obtain PA with no input from the prescribing physician. In contrast, some drugs will require more involvement from the prescribing physician in requesting prior authorization for an oral or selfadministered product. If physician involvement is required, the pharmacist may be able to provide details on what clinical information is required to obtain prior authorization. In cases, where the prescribing physician must request PA, a specific form may be required. State Medicaid websites, again could be helpful resources for identifying specific PA requirements and forms. Having access and copies of required PA forms in the office, could help expedite communication between the prescribing physician and pharmacy, minimizing delayed access to therapy for the patient. Additional information on prior authorization is included in the “Reimbursement Tools” section of this billing guide. Private Payer Prescription Drug Coverage Prescription drug benefits for private commercial payers vary considerably. Private payers commonly use benefit designs and formularies for generic drugs and preferred brand therapies such as tiered benefit structures. For claims processing efficiency and to minimize patient access issues, it is common that any requirement for prior authorization can be handled by the pharmacy submitting the claim. However, there are situations where the prescribing physician will need to provide additional medical justification in order for the prescribed therapy to be approved. Unlike access through public payers, access to a private plan’s formulary or drug restriction requirements is not always available on the plan website. However, conducting a detailed patient-specific benefit investigation to identify coverage, patient cost-sharing and specifics on any required prior authorization is a common best practice. Investigating a patient’s prescription drug benefit allows the office staff to provide comprehensive support for the patient.

IV. ORAL AND SELF-ADMINISTERED THERAPIES

53

Notes

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­­­Section 5 Fractures of bones as a result of osteoporosis often result in hospitalization. Treatments can include site immobilization using casts, splints or other devices to hold a fracture in the correct position for healing, or surgical procedure(s) to correct complex conditions. The most common fractures associated with osteoporosis are fractures of the hip, vertebrae and wrist.

Orthopedic–Inpatient

Types of Fractures There are two basic types of fractures: 1. Closed or simple fracture – one that does not produce an open wound of the skin. 2. Open or compound fracture – one in which a wound through the adjacent or overlying soft tissue communicates with the site of the break. These two types can be further subdivided into three types: 1.  Transverse – the fracture is at a right angle to the axis of the bone. 2.  Greenstick fracture – the bone is not fractured completely through and there is a bend in the bone. 3. Comminuted fracture – has small pieces, usually three or more, floating in the fracture area.

Diagnosis Coding Hospital services are billed using the ICD-9-CM diagnosis code(s) and procedure codes. Table 31 lists a number of ICD-9-CM codes that may be appropriate for osteoporosis or related conditions. Clinical documentation in the patient’s medical record should describe why the treating physician believes a fracture was caused by bone loss or other factors related to osteoporosis. Osteoporosis is classified into two major groups: primary and secondary. Primary osteoporosis implies that the condition is a fundamental disease entity. Secondary osteoporosis attributes the condition to an underlying clinical disease, medical condition or medication.45 The ICD sub-classification 733.1x reflects pathological fractures which are fractures at a site weakened by preexisting disease, as differentiated from traumatic fractures.

45. 2007 Ingenix; Coders’ Desk Reference for Diagnosis, 2008. pg 534 55 V. Orthopedic-Inpatient

Table 31. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Conditions46 ICD-9-CM Diagnosis Code

Description

733.00

Unspecified osteoporosis

733.01

Senile osteoporosis (Postmenopausal)

733.02

Idiopathic osteoporosis

733.03

Disuse osteoporosis

733.09

Other osteoporosis (drug-induced)

733.90

Disorder of bone and cartilage, unspecified

793.7

Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture

733.10

Pathologic fracture, unspecified site

733.11

Pathologic fracture of humerus

733.12

Pathologic fracture of distal radius and ulna (Wrist NOS)

733.13

Pathologic fracture of vertebrae (Collapse of vertebrae)

733.14

Pathologic fracture of neck of femur (Femur/Hip NOS)

733.15

Pathologic fracture of other specified part of femur

733.16

Pathologic fracture of tibia and fibula (Ankle NOS)

733.19

Pathologic fracture of other specified site

805.00-829.1

Fracture of Neck and Trunk (site specific)

V-Codes There are occasions when circumstances other than a disease or an injury justify an encounter with the health care delivery system or influence the patient’s current condition. V-codes are used to identify or define examinations, aftercare, ancillary services or therapy.47 Table 32 contains a list of some V-codes that may be appropriate for osteoporosis.

46. 2008 Ingenix; ICD-9-CM for Hospitals - Volumes 1, 2 and 3. 47. 2007 Ingenix; Coders Desk Reference for Diagnosis, 2008, pg. 655. 56

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Table 32. ICD-9-CM Diagnosis V-Codes for Osteoporosis48 V - Code

Description

V17.81

Family history of Osteoporosis

V54

Aftercare for healing pathologic fractures of arm, leg, hip, vertebrae

V54.20-29

Special screening for osteoporosis

Procedure Coding Appropriate ICD-9-CM procedure coding for osteoporosis is primarily based on the type of fracture the patient has sustained. Diagnoses and other clinical documentation in the patient’s medical record should support the need for specific hospital procedures. The following table provides a list of ICD-9-CM procedure codes that may be used to report osteoporosis-related diagnosis(es) or procedures Table 33. ICD-9-CM Procedure Codes for Osteoporosis-Related Orthopedic Procedures49 ICD-9-CM Procedure Code

Description

03.53

Repair of vertebral fracture

93.51-93.56

Other immobilization, pressure and attention to wound

97.88

Removal of external mobilization device

97.11-97.14

Nonoperative replacement of musculoskeletal and integumentary system appliance

93.41-93.46

Skeletal traction and other traction

79.0-79.9

Reduction of fracture or dislocation

78.8

Diagnostic procedures on bone, not elsewhere classified

88.94

Magnetic resonance imaging (MRI) of musculoskeletal

87.21-87.29, 87.43,88.21-88.33

Skeletal X-ray

81.40

Repair of hip, not elsewhere classified

48. 2008 Ingenix; Diagnosis, 2008 Coders Desk reference. 49. 2008 Ingenix; ICD-9-CM for Hospitals - Volumes 1, 2 and 3. 57 V. Orthopedic-Inpatient

Revenue Codes Medicare and private payers require hospitals to submit coded claims on the Uniform Billing claim form (UB-04). In addition to ICD-9-CM diagnosis and procedure codes, hospitals must also report four-digit revenue codes that identify resources such as surgical supplies, pharmacy and laboratory. These codes are typically grouped within itemized charges. Providers should verify coding requirements for specific payers since some payers have established codes specific to their plan. Table 34 lists revenue codes that may be associated with osteoporosis-related hospitalization resources. This list is not all-inclusive. Table 34. Revenue Codes Associated with Osteoporosis-Related Hospitalization Resources Revenue Codes

Description

0100

All inclusive Room and Board

0110

General Classification Room and Board - Private

0120

General Classification Room and Board - Semi Private

0250

General Classification - Pharmacy

0270

General Classification Med. Surg. Supplies

0279

Other Supplies/Devices

0300

General Classification Laboratory

0320

General Classification DX X-Ray

0360

General Classification - OR Services

0370

General Classification Anesthesia

0450

General Classification Emergency Room

0700

General Classification Cast Room

Medicare Coverage and Payment Chapter 1 of the CMS Medical Benefit Policy Manual, Section 1 defines the coverage criteria for inpatient hospital care.50 Medicare pays for hospitalization through the Part A benefit. Inpatient hospital services include bed and board, nursing and other related services. Medications, supplies, appliances and equipment are also included as well as certain diagnostic and therapeutic services. Medicare reimburses for inpatient care based on the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into a diagnosisrelated group (DRG). The table below identifies the Medicare MS-DRGs associated with osteoporosis and/or orthopedic procedures involving the hip, vertebrae 50. Medicare Benefit Policy Manual, Chapter 1 58

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or wrist. These MS-DRGs fall under the Major Diagnostic Category (MDC) of Disease and Disorders of the Musculoskeletal System and Connective tissue. Table 35 is intended to offer an example of potential DRGs and payment rates for these conditions and is not all-inclusive. Table 35. DRG Codes Related to Osteoporosis Hospitalizations51 MSDRG

MDC 08 Disease and Disorders of the Musculoskeletal System and Connective Tissue

2008 Medicare National Average Payment Rate

480

Hip and femur procedures except major joint with MCC

481

Hip and femur procedures except major joint with CC

$9,044.71

482

Hip and femur procedures except major joint without CC/MCC

$7,654.61

513

Hand or wrist procedures, except major thumb or joint procedures with CC/MCC

$5,748.30

514

Hand or wrist procedures, except major thumb or joint procedures without CC/MCC

$4,067.55

535

Fractures of the hip and pelvis with MCC

$5,302.05

536

Fractures of the hip and pelvis without MCC

$3,591.46

542

Pathological fractures and musculoskeletal and connective tissue malignancy with MCC

$7,279.32

543

Pathological fractures and musculoskeletal and connective tissue malignancy with CC

$5,456.18

544

Pathological fractures and musculoskeletal and connective tissue malignancy without CC/MCC

$4,596.97

553

Bone diseases and arthropathies with MCC

$4,501.07

554

Bone diseases and arthropathies without MCC

$3,168.22

562

Fractures, sprains, strains and dislocations except femur, hip, pelvis and thigh with MCC

$5,462.06

563

Fractures, sprains, strains and dislocations except femur, hip, pelvis and thigh without MCC

$3,415.80

564

Other Musculoskeletal System and Connective Tissue Diagnoses with MCC

$5,678.82

565

Other Musculoskeletal System and Connective Tissue Diagnoses with CC

$4,405.17

566

Other Musculoskeletal System and Connective Tissue Diagnoses without CC/ MCC

$3,811.65

640

Nutritional and miscellaneous metabolic disorders with MCC

$4,791.71

641

Nutritional and miscellaneous metabolic disorders without MCC

$3,546.45

$11,756.41

51. 4th Edition, DRG Expert, 2008 Ingenix, Appendix D 59 V. Orthopedic-Inpatient

Medicaid Coverage and Payment Most Medicaid programs reimburse services provided in the hospital inpatient setting services based on a modified version of the Medicare DRG payment system or case rates. Payment amounts under these state-specific DRG systems usually function similarly to Medicare’s DRG system, but are typically lower. Some Medicaid programs may pay for inpatient services based on discounted charges or per diem rates, which are all-inclusive payment amounts for each inpatient day of stay. Some states may restrict patient benefits by limiting the number of inpatient hospital days covered or by setting a cap on the maximum dollar amount that will be paid per fiscal year. Because Medicaid coverage and payment for inpatient services varies from state to state it is important to check with your local state Medicaid program to determine specific coverage criteria and reimbursement methodologies.

Private Insurance Coverage and Payment Private payers vary considerably in how they cover and reimburse for hospital inpatient services. Many private payers use a payment method in which most or all services, supplies and medications are included in a comprehensive daily or “per diem” rate. Some commercial and managed care plans reimburse inpatient services based on case rates, “usual, customary and reasonable” (UCR) charges, or discounted charges. Hospitals include considerations for therapies within their contracted rates with individual payers which define levels of service, authorization requirements and treatment plan specifics. It is important that you contact each individual private insurance plan to determine their specific coverage and billing guidelines for services provided in the inpatient setting.

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­­­Section 6 Fracture treatment in the outpatient setting is limited to splinting, casting, bracing, cast bracing and placement of other devices not requiring surgery. Most orthopedic practices have trained cast technicians on staff and in many cases the orthopedist himself may perform the necessary procedure.

Orthopedic– Outpatient

Diagnosis Coding There are several ICD-9-CM codes that may be appropriate for osteoporosis or related conditions. Clinical documentation in the patient’s medical record should describe why the treating physician believes a fracture was caused by bone loss or other factors related to osteoporosis. Osteoporosis is classified into two major groups: primary and secondary. Primary osteoporosis implies that the condition is a fundamental disease entity. Secondary osteoporosis attributes the condition to an underlying clinical disease, medical condition or medication.52 The ICD-9-CM diagnosis code 733.X reflects pathological fractures which are fractures at a site weakened by preexisting disease, as differentiated from traumatic fractures. Table 36. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Conditions ICD-9-CM Diagnosis Code

Description

733.00

Unspecified osteoporosis

733.01

Senile osteoporosis (Postmenopausal)

733.02

Idiopathic osteoporosis

733.03

Disuse osteoporosis

733.09

Other osteoporosis (drug-induced)

733.90

Disorder of bone and cartilage, unspecified

793.7

Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture

733.10

Pathologic fracture, unspecified site

733.11

Pathologic fracture of humerus

733.12

Pathologic fracture of distal radius and ulna (Wrist NOS)

733.13

Pathologic fracture of vertebrae (Collapse of vertebrae)

733.14

Pathologic fracture of neck of femur (Femur/Hip NOS)

52. 2006 Ingenix; Coders Desk Reference for Diagnosis, pg. 550 61 VI. Orthopedic-Outpatient

ICD-9-CM Diagnosis Code

Description

733.15

Pathologic fracture of other specified part of femur

733.16

Pathologic fracture of tibia and fibula (Ankle NOS)

733.19

Pathologic fracture of other specified site

805.00-829.1

Fracture of Neck and Trunk (site specific)

Procedure Coding for Vertebroplasty and Kyphoplasty for Compression Fractures of the Spine Older patients with soft and brittle bones, or osteoporosis, sometimes suffer from the collapse or fracture of the vertebrae. These compression fractures cause pain and loss of mobility and in some cases, kyphosis, leading to a “hunchback” appearance. Two procedures that may be considered for treating this condition are vertebroplasty and kyphoplasty. Vertebroplasty is considered a minimally noninvasive procedure to relieve pain that strengthens a broken vertebra and typically takes only an hour of surgical time. The procedure involves the injection of an orthopedic cement mixture through a needle into the fractured bone and generally requires local anesthesia and mild sedation. Kyphoplasty is a relatively new procedure that is also performed for the purposes of pain relief and to stabilize a vertebral fracture. It differs from vertebroplasty in that it requires two incisions in the back, balloons are used to create a cavity for the cement and there is no pressure required to inject the cement. The following table contains a list of CPT codes that may be appropriate to identify the vertebroplasty and kyphoplasty procedures. Table 37. CPT Codes for Vertebroplasty and Kyphoplasty

62

Code

Description

22520

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic

22521

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar

22522

Each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

22523

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar

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Code

Description

22524

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation ( e.g., kyphoplasty); lumbar

22525

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); Each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)

77002

Flouroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

77003

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction

Modifiers Two modifiers that may be appropriate to include on an outpatient orthopedic claim are LT and RT. These modifiers are used to indicate procedures performed on the left (LT) or right (RT) side of the body. Coding for Evaluation and Management Services (Office Visits) Office visits with patients may be scheduled to provide follow-up care or ongoing management of osteoporosis. There are seven components that are used to determine the appropriate level of Evaluation and Management (E&M) code that should be selected for a routine office visit. These components are: • History • Examination • Medical decision-making • Counseling • Coordination of care • Nature of presenting problem • Time History, examination and medical decision-making are the key components in determining the appropriate level of E&M service to bill. The following four considerations can assist you in identifying the service provided: • P  roblem Focused – limited to chief complaint, brief history, one affected body area examined and medical decision is straight forward. 63 VI. Orthopedic-Outpatient

• E  xpanded Problem Focused – limited to chief complaint, brief history, the affected body area examined and at least one other related organ system, medical decision is of low complexity. • D  etailed – Chief complaint, extended history taken, extended exam of the affected area and other symptomatic or related organ system(s), medical decision is of moderate complexity. • C  omprehensive - Chief complaint, extended history of the chief complaint and systems related to the problem, a complete past, family and social history, medical decision process is of high complexity. The following table contains a list of CPT codes that may be appropriate to identify office visits for patients with osteoporosis. Table 38. CPT Evaluation and Management (Office Visit) Codes CPT Code

Description

New Patient 99201

Office or other outpatient visit; problem focused

99202

Office or other outpatient visit; expanded problem focused

99203

Office or other outpatient visit; detailed

99204

Office or other outpatient visit; comprehensive—45 minutes

99205

Office or other outpatient visit; comprehensive—60 minutes

Established Patient 99211

Office or other outpatient visit; 5 minutes

99212

Office or other outpatient visit; problem focused

99213

Office or other outpatient visit; expanded problem focused

99214

Office or other outpatient visit; detailed

99215

Office or other outpatient visit; comprehensive

Consultations A consultation is a type of service initiated by one physician seeking additional advice or information regarding a patient’s condition or ongoing management.53 A primary care provider may seek consultation from an orthopedic physician for evaluation or continued management of an osteoporosis patient. Table 39 lists CPT codes that may be appropriate for consultations.

53. American Medical Association; CPT 2007; Evaluation and Management section; pg 14. 64

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Table 39. CPT Consultation Codes Code

Description

99241

Office consultation; problem-focused

99242

Office consultation; expanded problem-focused

99243

Office consultation; a detailed

99244

Office consultation; a comprehensive; 60 minutes

Some payers do not reimburse for a drug administration procedure and an evaluation and management code reported on the same date of service. For example, Medicare will not allow CPT code 99211 to be billed on the same date of service as a drug administration code. Some payers require providers to use a modifier to demonstrate that the E/M procedure was a separate service from other services rendered on the same date: -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

Medicare Coverage and Payment Coverage Vertebroplasty and kyphoplasty are typically performed in the hospital and Medicare provides coverage for these procedures performed in the outpatient setting. There are no National Coverage Determinations (NCDs) for vertebroplasty and kyphoplasty, but numerous Local Coverage Determinations (LCDs) exist for both procedures. These LCDs outline indications and coverage restrictions and may stipulate absolute contraindications (e.g. tumor mass causing significant spinal canal compromise), limitations such as one procedure per lifetime per vertebra or procedure codes that are not appropriate to bill to represent these procedures. Therefore, it is important for you to contact your local Medicare contractor to determine coverage guidelines for these procedures. Payment Vertebroplasty and kyphoplasty performed in the hospital outpatient setting are reimbursed under the Hospital Outpatient Prospective Payment System (OPPS). Table 40 summarizes the procedure codes for vertebroplasty and kyphoplasty, the Ambulatory Payment Classifications (APCs) to which these codes map and the national payment rates for these APCs. We have also included the allowed amounts for the professional services provided by the physician performing the procedure.

65 VI. Orthopedic-Outpatient

Table 40. Medicare Payment for Vertebroplasty and Kyphoplasty Procedures Performed in the Hospital Outpatient Setting 54 55 Code

Description

APC

2008 National APC Payment54

22520

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic

0050

$1,859.23

$557.59

22521

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar

0050

$1,859.23

$526.36

22522

Each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

0050

$1,859.23

$236.14

22523

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation ( e.g., kyphoplasty); lumbar

0052

$5,058.56

$575.88

22524

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation ( e.g., kyphoplasty); lumbar

0052

$5,058.56

$551.12

22525

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

0052

$5,058.56

$256.71

77002

Flouroscopic guidance for needle placement ( e.g., biopsy, aspiration, injection, localization device)

N/A

Payment packaged into payment for other services; no separate APC payment

2008 Medicare National Average Physician Fee Schedule Allowable55

N/A

Table 41 provides Medicare payment rates for evaluation and management services (office visits) and consultations provided in the physician office setting.

54. CMS. Hospital Outpatient Prospective Payment System. Addendum B. Updated April 2008. 55. CMS. 2008 National Physician Fee Schedule Relative Value File. Revised January 3, 2008. Facility Transitional Allowable with .8806 budget neutrality factor to Work RVU. 66

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Table 41. Outpatient Reimbursement for E/M and Consultations

56

Code

Description

2008 Medicare National Average Physician Fee Schedule Allowable56

99201

Office or other outpatient visit for the evaluation and management of a new patient (Level 1)

$22.09

99202

Office or other outpatient visit for the evaluation and management of a new patient (Level 2)

$42.66

99203

Office or other outpatient visit for the evaluation and management of a new patient (Level 3)

$65.51

99204

Office or other outpatient visit for the evaluation and management of a new patient (Level 4)

$108.93

99205

Office or other outpatient visit for the evaluation and management of a new patient (Level 5)

$141.68

99211

Office or other outpatient visit for the evaluation and management of an established patient (Level 1)

$8.38

99212

Office or other outpatient visit for the evaluation and management of an established patient (Level 2)

$22.09

99213

Office or other outpatient visit for the evaluation and management of an established patient (Level 3)

$41.90

99214

Office or other outpatient visit for the evaluation and management of an established patient (Level 4)

$65.51

99215

Office or other outpatient visit for the evaluation and management of an established patient (Level 5)

$94.07

99241

Office consultation; problem focused history

$31.61

99242

Office consultation; expanded problem focused history

$66.65

99243

Office consultation; a detailed history

$92.93

99244

Office consultation; a comprehensive history; 60 minutes

$145.49

99245

Office consultation; a comprehensive history; 80 minutes

$182.82

Some payers do not reimburse for a drug administration procedure and an evaluation and management code reported on the same date of service. For example, Medicare will not allow CPT code 99211 to be billed on the same date of service as a drug administration code. Some payers require providers to use a modifier to demonstrate that the E/M procedure was a separate service from other services rendered on the same date:

-25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

 6. CMS. 2008 National Physician Fee Schedule Relative Review File. Revised January 3, 5 2008. Facility Transitional Allowable with .8806 budget neutrality factor to Work RVU. 67 VI. Orthopedic-Outpatient

Medicaid Coverage and Payment Because Medicaid coverage and payment for outpatient orthopedic procedures varies it is important to check with your local state Medicaid program to determine coverage and reimbursement as well as billing requirements for these procedures. Most state Medicaid programs have adopted fee-schedule mechanisms similar to Medicare to reimburse for physician office services. Actual payment amounts vary, and Medicaid payment levels are typically well below the Medicare fee-schedule amount. Reimbursement methodologies for hospital outpatient services provided to Medicaid patients vary from state to state. Most states use either a modified version of the Medicare APC system, fee schedules or predetermined case rates. Private Payer Coverage and Payment Coverage guidelines and payment for outpatient orthopedic procedures vary by payer and patient-specific plan. Physician office services are a standard, covered benefit for most private plans. Payers may base their payment rates on contracted fee schedule amounts, usual and customary rates, a percentage of the provider’s charge, capitation rates or a percentage of allowed charges. Hospitals include considerations for therapies within their contracted rates with individual payers which define levels of service, authorization requirements and treatment plan specifics. It is important that you contact each individual private insurance plan to determine their specific coverage and billing guidelines for orthopedic procedures provided in the outpatient setting.

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­­­Section 7 Physical Therapy (PT) and Occupational Therapy (OT) provide rehabilitation intervention necessary to ensure functional restoration for patients who have experienced fractures as a result of osteoporosis. PT and OT may include services such as goal-oriented exercise regimen(s) and pain management and can be ordered by a physician to support the clinical plan of care and the rehabilitation process.

Inpatient Physical and Occupational Therapy

Diagnosis Coding Unless included within standing orders or as part of clinical guidelines, a physician will write an order for PT or OT services for the hospitalized patient. Table 42 lists the ICD-9-CM diagnosis codes that may be appropriate for patients hospitalized due to fracture(s). Due to the complex nature of osteoporosis and the wide variety of potential reasons for hospitalization, this list only includes a sample of diagnoses associated with fractures seen within the population and is not all-inclusive. Table 42. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Fracture57 Code

Description

Code

Description

733.00

Unspecified osteoporosis

733.11

Pathologic fracture of humerus

733.01

Senile osteoporosis

733.12

Pathologic fracture of radius and ulna

733.02

Idiopathic osteoporosis

733.13

Pathologic fracture of vertebrae

733.03

Disuse osteoporosis

733.14

Pathologic fracture of neck of femur

V-Codes There are occasions when circumstances other than a disease or an injury justify an encounter with the health care delivery system or influence the patient’s current condition. V-codes are used to identify or define examinations, aftercare, ancillary services, or therapy.58 Table 43 contains a list of some V-codes that may be appropriate for osteoporosis.

 International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 57. 2008 Expert, Ingenix, 2007. 58. ibid. 69 VII. Inpatient Physical and Occupational Therapy

Table 43. ICD-9-CM V-Codes Related to Osteoporosis Code

Description

V17.8

Other musculoskeletal diseases

V17.81

Osteoporosis

V54

Other orthopedic aftercare

V54.20 through V54.29

Aftercare for healing pathologic fractures (arm (unspecified), upper arm, lower arm, hip, leg (unspecified), upper leg, lower leg, vertebrae, other bone)

Coding for Therapeutic Procedures PT services are categorized as evaluation, management and modalities. ICD-9-CM procedure codes 93.0 through 93.09 are related to evaluation and testing procedures. Table 44 provides examples of these codes that may support these types of interventions. This list is not meant to be a complete listing of all therapeutic procedure codes. Table 44. PT Evaluation and Testing ICD-9-CM Procedure Codes59 Code

Description

Physical therapy, respiratory therapy, rehabilitation and related procedures 93.01

Functional evaluation

93.04

Manual testing of muscle function

93.05

Range of motion testing

ICD-9-CM procedure codes 93.1x through 93.4x are codes that support physical therapy management such as exercises, training, manipulation or modalities which include properties of heat, cold, air, light, water, electricity, ultrasound and traction. Table 45 provides an example of potential therapy codes that may support these types of interventions. This list is not meant to be a complete listing of all therapeutic procedure codes.

59. International Classification of Diseases, 9th Revision, Clinical Modification 6th Edition, 2008 Expert, Ingenix, 2007. 70

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Table 45. PT Management ICD-9-CM Procedure Codes Code

Description

93.11

Physical therapy exercises – Assisting exercises

93.14

Physical therapy exercises – Training in joint movements

93.15

Physical therapy exercises – Mobilization of spine

93.16

Physical therapy exercises – Mobilization of other joints

93.17

Physical therapy exercises – Other passive musculoskeletal exercise

93.18

Physical therapy exercises – Breathing exercise

93.19

Physical therapy exercises – Exercise, not elsewhere classified

93.21

Other physical therapy musculoskeletal manipulation – Manual and mechanical traction

93.22

Other physical therapy musculoskeletal manipulation – Ambulation and gait training

93.42

Skeletal traction and other traction – Other spinal traction

OT services related to “Activities of Daily Living” are coded using ICD-9-CM procedure codes 93.83. Other services that support splinting/casting use ICD-9CM procedure codes 93.51 through 93.54. Table 46 provides an example of potential therapy codes that may support these types of interventions. This list is not meant to be a complete listing of all therapeutic procedure codes. Table 46. OT Related ICD-9-CM Procedure Codes Code

Description

Other immobilization, pressure and attention to wound 93.51

Application of plaster jacket

93.52

Application of neck support

93.53

Application of other cast

93.54

Application of splint

Other rehabilitation therapy 93.83

Occupational therapy (daily living activities therapy)

93.89

Rehabilitation, not elsewhere classified

Revenue Codes In addition to ICD-9-CM diagnosis and procedure codes, hospitals must also report four-digit revenue codes that identify resources such as therapies. These codes are typically grouped within itemized charges. Providers should verify coding requirements for specific payers since some payers have established codes 71 VII. Inpatient Physical and Occupational Therapy

specific to their plan. Table 47 lists general revenue codes that may be associated with osteoporosis hospitalization resources. This list is not all-inclusive. Table 47. Revenue Codes Related to Osteoporosis Hospitalization Resources Revenue Codes

Description

0420

General Classification - PT

0421

Visit Charge - PT

0422

Hourly Charge - PT

0423

Group Rate - PT

0424

Evaluation or Re-Evaluation - PT

0429

Other Physical Therapy

0430

General Classification - OT

0431

Visit Charge - OT

0432

Hourly Charge - OT

0433

Group Rate - OT

0434

Evaluation or Re-Evaluation - OT

0439

Other Occupational Therapy

Medicare Coverage and Payment Coverage Rehabilitation provided in a hospital inpatient setting or special rehabilitation unit is covered under Medicare Part A. Medicare coverage of inpatient hospital rehabilitation is based on the level of rehabilitation required. The Medicare Benefits Policy Manual defines the inpatient hospital rehabilitation need as requiring and receiving at least three hours a day of physical and/or occupational therapy. Because individual needs vary, exceptions could occur.60 Payment Medicare reimburses for inpatient care under the inpatient prospective payment system (IPPS). Medicare will cover PT and OT services within the bundled reimbursement of the corresponding Medicare severity diagnosis related group (MS-DRG). The table below identifies the MS-DRGs associated with osteoporosis and/or orthopedic procedures involving the hip, vertebrae or wrist.61 Table 48 is intended to offer examples of potential MS-DRGs and 2008 average Medicare payment rates for these conditions, and is not all-inclusive. 60. Medicare Benefits Policy Manual, Chapter 1. 61. These DGRs fall under the Major Diagnostic Category (MDC) of Disease and Disorders of the Musculoskeletal System and Connective tissue. 72

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Table 48. DRG Codes Related to Osteoporosis-related Hospitalizations62 DRG

MDC 08 Disease and Disorders of the Musculoskeletal System and Connective Tissue

2008 Medicare National Average Payment Rate

480

Hip and femur procedures except major joint with MCC

$11,756.41

481

Hip and femur procedures except major joint with CC

$9,044.71

482

Hip and femur procedures except major joint without CC/MCC

$7,654.61

513

Hand or wrist procedures, except major thumb or joint procedures with CC/MCC

$5,748.30

514

Hand or wrist procedures, except major thumb or joint procedures without CC/MCC

$4,067.55

535

Fractures of the hip and pelvis with MCC

$5,302.05

536

Fractures of the hip and pelvis without MCC

$3,591.46

542

Pathological fractures and musculoskeletal and connective tissue malignancy with MCC

$7,279.32

543

Pathological fractures and musculoskeletal and connective tissue malignancy with CC

$5,456.18

544

$4,596.97

553

Pathological fractures and musculoskeletal and connective tissue malignancy without CC/MCC Bone diseases and arthropathies with MCC

554

Bone diseases and arthropathies without MCC

$3,168.22

562

Fractures, sprains, strains and dislocations except femur, hip, pelvis and thigh with MCC

$5,462.06

563

$3,415.80

564

Fractures, sprains, strains and dislocations except femur, hip, pelvis and thigh without MCC Other Musculoskeletal System and Connective Tissue

565

Other Musculoskeletal System and Connective Tissue Diagnoses with CC

$5,678.82

566

Other Musculoskeletal System and Connective Tissue Diagnoses without CC/MCC

$3,811.65

640

Nutritional and miscellaneous metabolic disorders with MCC

$4,791.71

641

Nutritional and miscellaneous metabolic disorders without MCC

$3,546.45

$4,501.07

$5,678.82

Medicaid Coverage and Payment Most Medicaid programs reimburse services provided in the hospital inpatient setting services based on a modified version of the Medicare DRG payment system, per diem, or case rates. Payment amounts under these state-specific DRGs vary from state to state. Some Medicaid programs may pay for inpatient services based on discounted charges or per diem rates, which are all-inclusive payment amounts for each inpatient day of stay. Some states may restrict patient benefits by limiting the number of inpatient hospital days covered or by setting a cap on the maximum dollar amount that will be paid per fiscal year. Because Medicaid coverage and payment for inpatient services varies from state to 62 4th Edition, DRG Expert, Ingenix 2008, Appendix D. 73 VII. Inpatient Physical and Occupational Therapy

state it is important to check with your local state Medicaid program to determine the coverage and reimbursement for PT and OT as well as billing requirements for therapy services.

Private Payer Coverage and Payment Private payers vary considerably in how they cover and reimburse for hospital inpatient services. Hospitals include considerations for therapies within their contracted rates with individual payers which define levels of service, authorization requirements and treatment plan specifics. It is important that you contact each individual private insurance plan to determine their specific coverage and billing guidelines for PT and OT in the inpatient setting.

Physical and Occupational Therapy Provided in the Skilled Nursing Facility (SNF) Medicare Coverage Post-hospital care provided to beneficiaries in skilled nursing facilities (SNFs) is covered and reimbursed under a patient’s Medicare Part A benefit. Skilled nursing facility coverage includes the following services: • Physical therapy • Occupational therapy • Nursing care provided by registered professional nurses • Bed and board • Speech therapy • Social services • Medications, supplies and equipment According to Medicare guidelines, services provided in a SNF should be covered and reimbursed if the following conditions are met: • P  atient was hospitalized for at least three days and was admitted to the SNF within 30 days of hospital discharge • Physician certifies the need for SNF care • P  atient requires skilled rehabilitation services and/or skilled nursing services (rendered by nurses, physical therapists, or occupational therapists), on a daily basis (five days a week) • SNF is a Medicare-certified facility

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Medicare Payment Services provided in a SNF are reimbursed by Medicare under a prospective per diem rate, based on a case-mix system, for up to 100 days. This system measures the type and intensity of care required by each SNF resident as well as the resources utilized to provide this care. Base payment rates are determined separately for urban and rural areas and adjusted for geographic and case-mix differences. A classification system, called Resource Utilization Groups (RUGs) places each Medicare SNF resident into one of the following seven major classifications: • Rehabilitation

• Extensive Services

• Special Care

• Clinically Complex

• Impaired Cognition

• Behavior Only

• Decreased Physical Function The seven major RUG classifications are subdivided into a total of 53 categories and each resident is placed into only one classification. The 53 group RUG classification system went into effect January 1, 2006, replacing the 44 group RUG system and added 9 new payment groups for patients who meet the criteria for “extensive services” and “rehabilitation” groups. Assignment of a patient to one of the RUGs is based on the following: • N  umber of minutes of therapy (physical, occupational, or speech) that the patient has used or is expected to use • The need for specific services (e.g., respiratory therapy or specialized feeding) • The presence of certain ailments or conditions(e.g., pneumonia or dehydration) • T  he patient’s ability to perform independently four activities of daily living (ADLs) including eating, toileting, bed mobility and transferring • Signs of depression, in some cases. Table 49 provides the Medicare daily base rates for therapy for rehabilitation RUGS in the SNF. Table 49. 2007 Medicare Daily Base Rates for Therapy for Rehabilitation RUGs63 Rate Component

Therapy (for rehabilitation RUGs)

Urban rate

$110.44

Rural rate

$127.35

It is critical that SNF providers understand the RUG classification system, as appropriate patient classification impacts both Medicare coverage and reimbursement.

63. 72 Fed. Reg. 43416 (2007). 75 VII. Inpatient Physical and Occupational Therapy

Medicaid Coverage and Payment Nursing facility services for beneficiaries age 21 and older is a required Medicaid benefit. Typically, Medicaid programs include reimbursement for PT and OT services provided in a SNF in a per diem rate. However, states will vary considerably in how they cover and reimburse for physical and occupational therapy provided in the SNF setting. It is important to verify coverage and reimbursement information for physical and occupational therapy provided in the SNF setting with your local state Medicaid agency.

Private Payer Coverage and Payment Private payers typically cover physical and occupational therapy provided in a skilled nursing facility, though specific restrictions and limitations will often apply. Private payers may limit skilled nursing services to instances when, for example, a patient is expected to improve significantly within 60 days. Reimbursement will vary depending on the specific payer, plan type and contractual arrangement with the SNF. You may want to contact your individual private payers to determine specific coverage policies and reimbursement methodologies.

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­­­Section 8 Physical therapists and occupational therapists can deliver their services to patients diagnosed with osteoporosis in a variety of outpatient settings. Most commonly their services are provided in the physician office setting, a private physical therapy and/or occupational therapy practice or as an outpatient service through a local hospital.

Outpatient Physical and Occupational Therapy

Diagnosis Coding A physician will write an order for PT or OT services for the patient provided in the outpatient setting. The table below lists the ICD-9-CM diagnosis codes that may be appropriate for patients receiving PT or OT services. Due to the complex nature of osteoporosis and the wide variety of potential reasons for receiving therapy, this list only includes diagnosis associated with the main types of fractures seen within the population and is not all-inclusive. Table 50. ICD-9-CM Diagnosis Codes for Osteoporosis and Related Fractures Code

Description

Code

Description

733.00

Unspecified osteoporosis

733.11

Pathologic fracture of humerus

733.01

Senile osteoporosis

733.12

Pathologic fracture of radius and ulna

733.02

Idiopathic osteoporosis

733.13

Pathologic fracture of vertebrae

733.03

Disuse osteoporosis

733.14

Pathologic fracture of neck of femur

Procedure Coding A CPT code is used to report each distinct procedure that is performed by the PT and OT in the outpatient setting. The CPT codes related to PT and OT are divided into three categories: evaluation services, modalities and therapeutic procedures. Evaluation services are services provided to the patient in a clinic setting or in a hospital outpatient setting that result in a diagnosis of disease and a plan of treatment. CPT codes relate to evaluation services are included in Table 51.

77 VIII. Outpatient Physical and Occupational Therapy

Table 51. CPT Evaluation Codes for PT and OT Code

Description

97001

Physical Therapy Evaluation

97002

Physical Therapy Re-evaluation

97003

Occupational Therapy Evaluation

97004

Occupational Therapy Re-evaluation

Modalities include a variety of treatment methods and tools used by therapists to reduce pain, inflammation and treat muscle strains. CPT codes relates to modalities are included in Tables 52 and Table 53. Table 52. CPT Modality Codes for PT Code

Description

97010

Application of a modality to one or more areas; hot or cold packs

97014

Electrical stimulation (unattended)

97022

Whirlpool

It is important to note that modalities requiring constant attendance of the physical therapist, occupational therapist or physician are billed in fifteen (15) minute increments which are referred to as billing units. For example, if the physical therapist spends 45 minutes applying iontophoresis to a patient, the billing units for that service would be “3” to indicate three 15-minute segments. Table 53. CPT Codes for Modalities Requiring Constant Attendance Code

Description

97032

Application of a modality to one or more area; electrical stimulation (manual), each 15 minutes

97033

Iontophoresis, each 15 minutes

Therapeutic procedures include the application of clinical skills or services to improve function. These procedures require direct one-on-one patient contact. The following are examples of CPT codes which may be used by physical therapists to report these therapeutic services.

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Table 54. CPT Therapeutic Procedure Codes for PT Code

Description

97110

Therapeutic Procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112

Therapeutic Procedure, neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities (each 15 minutes)

97116

Therapeutic Procedure, gait training (includes stair climbing) (each 15 minutes)

Occupational therapists may use the following codes when providing services to patients diagnosed with osteoporosis. This listing is not intended to be a complete listing of services provided to all OT patients. In some cases, where an occupational therapist is not available, a physical therapist may provide these services. It is important to note that these therapeutic codes are billed in time units of fifteen (15) minutes. Table 55. CPT Therapeutic Procedure Codes for OT Code

Description

97530

Therapeutic Services, direct (one-on-one) patient contract by the provider (use of dynamic activities to improve functional performance, each 15 minutes

97535

Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures and instructions in use of assistive technology devices/ adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97542

Wheelchair management (e.g., assessment, fitting, training), each 15 minutes

Modifiers When billing Medicare, providers are required to use modifier GP for physical therapy services and GO for occupational therapy. These modifiers must be indicated in the modifier section of the claim form. Failure to use these modifiers could result in claim denial. Additional information on appealing claim denials is included in the “Reimbursement Tools” section of this billing guide. Revenue Codes In addition to ICD-9-CM diagnosis codes and CPT codes, hospitals must also report four-digit revenue codes that identify resources such as therapies. These codes are typically grouped within itemized charges. Providers should verify cod79 VIII. Outpatient Physical and Occupational Therapy

ing requirements for specific payers since some payers have established codes specific to their plan. Table 56 lists general revenue codes that may be associated with osteoporosis-related hospital outpatient procedures. This list is not all-inclusive. Table 56. Revenue Codes Associated with Osteoporosis-Related Hospital Procedures Inpatient Revenue Codes

Description

0420

General Classification - PT

0421

Visit Charge - PT

0422

Hourly Charge - PT

0423

Group Rate - PT

0424

Evaluation or Re-Evaluation - PT

0429

Other Physical Therapy

0430

General Classification - OT

0431

Visit Charge - OT

0432

Hourly Charge - OT

0433

Group Rate - OT

0434

Evaluation or Re-Evaluation - OT

0439

Other Occupational Therapy

Medicare Coverage and Payment Coverage Medicare covers outpatient PT and OT services and Chapter 15 of the CMS Medical Benefit Policy Manual, Sections 220 and 230, establish the Medicare coverage criteria for these services. The primary conditions for coverage are as follows: • T  he services must be medically necessary. This is generally validated by the patient having a current diagnosis that indicates medical necessity. • T  he services must be delivered by a “qualified professional” who is defined as a physical therapist, occupational therapist, physician, nurse practitioner, clinical nurse specialist or physician’s assistant who is licensed in the state where they are performing therapy services. Physical therapy assistants (PTA) and occupational therapy assistants (OTA) may by state law be able to perform limited therapy services but only under the direct supervision of a qualified professional.

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• A  formal written Plan of Care has been designed for the patient and the plan is dated and signed by the licensed medical professional ordering the services and this plan must be periodically reviewed by a physician or other recognizes licensed medical professional. • The services are furnished while the patient is under the care of a physician. • Services must be furnished on an outpatient basis. Payment Medicare places a cap on therapy services including PT and OT provided to a single patient in a calendar year. In 2008, the cap is $1,810 for PT and $1,810 for OT and is applied when these services are provided in the outpatient setting and paid under the Physician Fee Schedule. Therefore, this limit does not apply to outpatient therapy services billed by hospitals, though hospitals are still required to document medical necessity. After the cap is reached, a patient must pay for therapy services for the remainder of the calendar year. Medicare has an “exception” policy that allows the therapist to exceed the cap, in certain instances. As of 2008, all exceptions to the cap are to be pursued using the automatic process where continued therapy services are documented as medically necessary.64 Documentation by the therapist is necessary to indicate the need for additional therapy beyond the cap in order for the patient to achieve prior or maximum functional status. The “KX” modifier should be added to each claim line for an outpatient therapy service procedure when the Medicare beneficiary is qualified for a therapy cap exception. Medicare payment in the office is based on the 2008 Medicare Physician Fee Schedule (MPFS). The following table lists the 2008 Medicare national average payment amounts for the codes that have been cited above that may be used by physical therapists (PTs) and occupational therapists (OTs) in the office setting.

64. 72 Fed. Reg. 66356 (2007). 81 VIII. Outpatient Physical and Occupational Therapy

Table 57. 2008 National Average Allowables for PT and OT Services Provided in the Office65 Code

Description

2008 Medicare National Average Allowable

97001

Physical Therapy Evaluation

$74.27

97002

Physical Therapy Re-evaluation

$39.61

97003

Occupational Therapy Evaluation

$79.22

97004

Occupational Therapy Re-evaluation

$46.47

97022

Whirlpool

$17.14

97032

Application of a modality to one or more area; electrical stimulation (manual), each 15 minutes

$16.76

97033

Iontophoresis, each 15 minutes

$23.99

97110

Therapeutic Procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

$28.95

97112

Therapeutic Procedure, neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/ or standing activities (each 15 minutes)

$30.09

97116

Therapeutic Procedure, gait training (includes stair climbing) (each 15 minutes)

$25.52

97530

Therapeutic Services, direct (one-on-one) patient contract by the provider (use of dynamic activities to improve functional performance, each 15 minutes

$30.47

97535

Self-care/home management training (e.g. activities of daily living (ADL) and compensatory training, meal preparation, safety procedures and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

$30.85

97542

Wheelchair management (e.g. assessment, fitting, training, each 15 minutes

$28.18

65. CMS. 2008 National Physician Fee Schedule Relative Value File. Revised January 3, 2008. Non-facility Transitional Allowable with .8806 budget neutrality factor to Work RVU. 82

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Table 58 lists the 2008 Medicare national average payment amounts for the codes that have been cited above that may be used by PTs and OTs in the hospital outpatient setting. Table 58. 2008 National Average Allowables for PT and OT Services Provided in the Hospital Outpatient Department Code

Description

2008 Medicare National Average Allowable

97001

Physical Therapy Evaluation

$69.94

97002

Physical Therapy Re-evaluation

$36.94

97003

Occupational Therapy Evaluation

$73.89

97004

Occupational Therapy Re-evaluation

$43.80

97010

Application of a modality to one or more areas; hot or cold packs

$16.38

97014

Electrical stimulation (unattended)

$15.62

97022

Whirlpool

$22.85

97032

Application of a modality to one or more area; electrical stimulation (manual), each 15 minutes

$27.04

97033

Iontophoresis, each 15 minutes

$28.18

97110

Therapeutic Procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

$68.94

97112

Therapeutic Procedure, neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/ or standing activities (each 15 minutes)

$36.94

97116

Therapeutic Procedure, gait training (includes stair climbing) (each 15 minutes)

$23.61

97530

Therapeutic Services, direct (one-on-one) patient contract by the provider (use of dynamic activities to improve functional performance, each 15 minutes

$28.57

97535

Self-care/home management training (e.g. activities of daily living (ADL) and compensatory training, meal preparation, safety procedures and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

$28.95

97542

Wheelchair management (e.g. assessment, fitting, training) each 15 minutes

$26.28

83 VIII. Outpatient Physical and Occupational Therapy

Medicaid Coverage and Payment Because Medicaid coverage and payment for outpatient PT and OT varies, it is important to check with your local state Medicaid program to determine coverage and reimbursement for PT and OT, as well as billing requirements for therapy services. Most state Medicaid programs have adopted fee-schedule mechanisms similar to Medicare to reimburse for PT and OT services provided in an office setting. Actual payment amounts vary, and Medicaid payment levels are typically well below the Medicare fee schedule amount. Reimbursement methodologies for hospital outpatient services provided to Medicaid patients vary from state to state. Most states use either a modified version of the Medicare APC system, fee schedules or predetermined case rates.

Private Payer Coverage and Payment Coverage guidelines and payment for PT and OT vary by payer and patient-specific plan. PT and OT services provided in an office setting are a standard, covered benefit for most private plans. Payers may base their payment rates on contracted fee schedule amounts, usual and customary rates, a percentage of the provider’s charge, capitation rates or a percentage of allowed charges. Hospitals include considerations for therapies within their contracted rates with individual payers which define levels of service, authorization requirements and treatment plan specifics. It is important that you contact each individual private insurance plan to determine their specific coverage and billing guidelines for PT and OT provided in the outpatient setting.

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­­­Section 9 Reimbursement for the treatment of osteoporosis will vary by payer and will differ as widely as the therapies and services that are prescribed. Some payers may establish coverage policies for a specific procedure, treatment or drug while other payers may not. Coverage, as defined by each payer type and benefit package, will vary according to site of service, patient condition and medical history. It is important for providers to conduct patient-specific insurance verification to determine coverage for a patient and if utilization controls are implemented by a payer. The following tools and resources may be of assistance when submitting claims for the treatment of osteoporosis. •

Benefit verification checklist

•

Sample claim forms

•

Sample letter of medical necessity

•

Sample letter of appeal and checklist

•

Claim denial checklist

•

Sample prior authorization request letter and checklist

•

Medicare Advance Beneficiary Notice (ABN)

­ eimbursement R Tools and References

85 IX. Reimbursement Tools & References

Checklist for Verifying Benefits The following tips may assist you with verification of benefits:.

When calling a payer to verify benefits the following key questions should be considered:  Is the product and/or procedure covered under the patient’s medical

benefit or pharmacy benefit? Is prior authorization required? 

Are there any site of service restrictions for the product and/or service?



What is the patient’s deductible? — Has it been met? If not, what amount has been applied to date?

 What is the patient’s copayment or coinsurance for the product and/or the

procedure? 

Does the patient have an out-of-pocket maximum? — Has it been met? If not, what amount has been applied to date?



Does the patient have an annual or lifetime benefit maximum? — Has it been met? If not, what amount has been applied to date?

 What are the coding and claim submission requirements for the product

and/or procedure? — Codes to report product and administration services — Claims telephone and address — Claims completion instruction — Required documentation (letter of medical necessity, patient notes) 

What is the reimbursement amount for the product and/or procedure?

 Does the patient have other insurance benefits that will need to be

coordinated?  Is the medication on the drug formulary? What type of drug formulary

does the plan offer (e.g., open, closed, or tiered drug formulary)? 

Does the medication have a dosage restriction or require step-therapy?

 Does the plan offer mail order prescriptions? Can the patient obtain a

90-day supply?  Are there any diagnoses restrictions for the service, procedure, or

product? 

Which pharmacy is considered an in-network pharmacy under the plan?

 Is pre-certification required for an inpatient or outpatient treatment?

If so, what is the process and what information is required?

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Sample Claim Forms CMS 1500 Claim Form—Example 1

CMS 1500 Claim Form—Example 2

CMS 1450/UB-40 Claim Form Sample

Sample Letter of Medical Necessity Some payers may require you to submit a Letter of Medical Necessity (LMN) for a product or procedure needed for the patient. The following is a sample letter of medical necessity.

[Date] [Insurance Company] [Address] [City, State, Zip Code] Insured: [Name] Policy Number: [Number] Group Number: [Number] Dear [Medical Director’s name], MD: I am writing on behalf of my patient, [patient name], to document medical necessity and request insurance coverage and appropriate payment for [insert name of service, procedure or product]. This letter provides information on the patient’s condition, medical history and treatment rationale, as well as [service/product/procedure] scientific literature demonstrating medical necessity. Patient History and Diagnosis [Patient name] is a [age] year old [male/female] with a diagnosis of [diagnosis and ICD-9-CM diagnosis code] as of [date of diagnosis]. [Patient name] has been in [my or treating physician’s name] care for [patient’s diagnosis] since [date]. As a result of [patient’s diagnosis], [he/she] [describe resulting condition, including results from any relevant patient lifestyle assessment.] [Provide a brief discussion of patient’s condition/ symptoms and therapy to date, including other treatments attempted and results.] [Provide a brief discussion of product and/or procedure including supportive documentation and reference based on peer-reviewed literature published at the time.] Based on the above facts, I am confident you will agree that [product/procedure] is indicated and medically necessary for this patient. Please feel free to call me at [physician telephone number] if you have any questions or require additional information regarding this patient’s treatment. Thank you in advance for your immediate attention to this request. Sincerely,

[Physician name] [Practice name] [NPI number or Provider number]

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Claim Denials and Appeals Payers may deny coverage and claims for a variety of reasons. Often, a claim denial is due to a payer processing error or inaccurate or incomplete information such as a missing identification number, patient name or signature. In the case of a payer error, many payers will allow the review process to be initiated via a telephone call to the payer’s claims department. In the event of an incomplete or inaccurate claim, the claim may be corrected and resubmitted for payment. In these cases, remember to clearly mark the claim for “resubmission” so that the payer will not deny it as a duplicate bill. Review the claim for submission errors. Claims may be denied because of variations in payer policies, confusion or lack of knowledge about services provided, lack of documentation in a patient’s medical record supporting treatment or due to technical billing systems, both provider and/or payer, that are not current. Claims denied due to payer policies may be successfully appealed when appropriate documentation is submitted to educate the payer about the efficacy and safety of the procedure/treatment. Common Reasons for Claim Denial 1. Incorrect or missing identification number 2. Incorrect or misspelled patient name 3. Use of incorrect code(s) 4. Missing modifier 5. Lack of documentation in patient record to justify medical necessity

Payers may impose strict time limits to submit an appeal, often requiring an appeal to be submitted within 30 to 60 days of the date of the claim denial. Failing to meet payer-specific appeal requirements may result in waiver or loss of appeal. To support your initial appeal, make sure to file all claims and appeals within specified time limits. The following items are recommended for an appeals packet: •

Letter of medical necessity and/or appeal

•

Copy of original claim form

•

Copy of denial notification from the payer

•

Patient’s complete medical history

• Relevant documentation supporting use of procedure or drug for treatment of patient’s condition •

Package insert

91 IX. Reimbursement Tools & References

Best Practices for Appealing Denied Claims •

Review Explanation of Benefits (EOB) to determine reason for the denial.

• If additional information is requested, submit the necessary documentation immediately. • Submit a corrected claim if the denial was due to a billing error (e.g., incorrect identification number, missing diagnosis). •

Verify appeals process with payer.

•

Review appeal request for accuracy.

•

File claims appeal as soon as possible and within filing time limits.

• Reconcile claims appeal responses promptly and thoroughly to ensure appeals have been appropriately processed. • Record appeal results (e.g., payment amount or if further action is required).

A sample letter of appeal is provided for your use and may be customized with detailed patient information to accurately describe the patient’s condition and substantiate medical necessity. Although most payers allow health care providers to create customized appeal packets, some require that a specialized form be completed to initiate the appeal process. Be sure to check with each individual payer to determine the correct procedure to file an appeal. If the first appeal is denied, it may be necessary to contact the payer’s medical or pharmacy director. Claims denials are often reversed when submitted beyond a first-level appeal.

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Sample Letter of Appeal The following template may be adapted to submit a letter of appeal.

[Date] [Insurance Company] [Address] [City, State, Zip Code] Insured: [Name] Policy Number: [Number] Group Number: [Number] Date(s) of Service: [Date of service for claim denial] Provider Name: [Name] NPI#: [Number] RE: Request for Reconsideration of Claim for [insert service or drug], [insert applicable code] Dear [Medical Director’s name], MD: This letter serves as a request for reconsideration of denied claim [insert claim #] for [patient name], policy number [insert policy #]. The denied claim represents treatment for [insert name of service, procedure, or drug, and applicable code], which was performed on [date of service]. Patient History and Diagnosis [Patient name] is a [age] year old [male/female] with a diagnosis of [diagnosis and ICD-9 code] as of [date of diagnosis]. [Patient name] has been in [my or treating physician’s name] care for [patient’s diagnosis] since [date.] As a result of [patient’s diagnosis], [he/she] [describe resulting condition, including results from any relevant patient lifestyle assessment.] [Provide a brief discussion of patient’s condition/symptoms and rationale for therapy to date, including other treatments attempted and results. Include rationale for service, procedure, or drug that was denied.] [Provide a brief discussion of product and/or procedure including supportive documentation and reference based on peer-reviewed literature published at the time. Include name of article(s) and brief abstract(s) which are most pertinent to case, and a list of other supportive articles.] In my professional opinion, I believe [insert name of service, procedure, or drug] was medically necessary and a clinically appropriate treatment for [patient name] on the above referenced date(s). Thank you in advance for your review and consideration of this appeal. Please feel free to call me at [physician telephone number] if you have any questions or require additional information regarding this case. Please notify me in writing of your coverage decision as soon as possible. Sincerely, [Physician name] [Practice name] [NPI number or Provider number]

93 IX. Reimbursement Tools & References

Sample Prior Authorization Request Coverage and reimbursement for a service, procedure, or drug will vary depending on a patient’s insurance coverage and the site of service. Many payers may require prior authorization approval before certain health care services are rendered to a patient. Prior authorization allows the payer to review the rationale for a requested treatment/therapy to determine medical necessity. The payer may utilize a payerspecific form or allow a provider to submit an authorization request letter. The following template may be adapted to submit a prior authorization request on behalf of a patient. Providers are encouraged to verify prior authorization requirements for each plan when applicable.

[Date] [Insurance Company] [Address] [City, State, Zip Code] Insured: [Name] Policy Number: [Number] Group Number: [Number] Date(s) of Service: [Anticipated Date of service] Provider Name: [Name] NPI#: [Number] RE: Prior Authorization Request for [insert service or drug], [insert HCPCS #] Dear [Medical Director’s name], MD: I am writing on behalf of my patient, [name of patient] to request prior authorization approval for [insert name of service, procedure, or drug, and applicable code]. This letter outlines the patient’s condition, medical history, prognoses, and treatment rationale. Patient History and Diagnosis [Patient name] is a [age] year old [male/female] with a diagnosis of [diagnosis and ICD-9 diagnosis code] as of [date of diagnosis]. [Patient name] has been in [my or treating physician’s name] care for [patient’s diagnosis] since [date]. As a result of [patient’s diagnosis], [he/she] [describe resulting condition, including results from any relevant patient lifestyle assessment.] [Provide a brief discussion of patient’s condition/symptoms and therapy to date, including other treatments attempted and results.] [Provide a brief discussion of product and/or procedure including supportive documentation and reference based on peer-reviewed literature published at the time.] Based on the above facts, I am confident you will agree that [product/procedure] is indicated and medically necessary for this patient. Please feel free to call me at [physician telephone number] if you have any questions or require additional information regarding this patient’s treatment. Thank you in advance for your immediate attention to this request. Sincerely, [Physician name] [Practice name] [NPI number or Provider number]

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Checklist for Obtaining Prior Authorization The following tips will assist you when completing the prior authorization process.

When calling a payer to inquire about prior authorization, the following questions should be considered: 

Is prior authorization required?



What is the prior authorization process (special form, letter of medical necessity)?



What is the phone or fax number for the authorization department?



Can the prior authorization form/letter be submitted via fax or mail?



What information is required?



What is the timeframe for a decision?



How will the decision be communicated (e.g., phone or fax)?

 How often must a prior authorization request be submitted (e.g., monthly, every 60 days, every six months, or

annually)? 

What is the process to appeal a prior authorization denial?

Medicare Advanced Beneficiary Notice An Advanced Beneficiary Notice (ABN) is a written notice given to a Medicare beneficiary to explain that Medicare may not pay for an item or service based upon lack of medical necessity. The ABN allows the Medicare beneficiary to make an informed decision whether or not to receive the items or services for which he or she may have to pay out-of-pocket. The patient must sign the ABN and the patient may be billed if the claim is subsequently denied. Medicare Part B has two different forms providers may use: •

 he ABN-G is a general notice that may be used for any service that the proT vider believes Medicare will not pay for based on medical necessity. (Please see example on next page.)

•

 he ABN-L is a notice only to be used by laboratories T (labs may also use the ABN-G).

These forms are available on the CMS website at http://www.cms.hhs.gov/BNI/. If your patients have questions about the ABN, there is also a patient-brochure available on the CMS website at http://www.cms.hhs.gov/MLNProducts/ Downloads/ABN_READERS.pdf.

95 IX. Reimbursement Tools & References

Sample ADVANCE BENEFICIARY NOTICE

(A) Notifier(s): (B) Patient Name:

(C) Identification Number:

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If Medicare doesn’t pay for (D)_____________ below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D)_____________ below. (D) (E) Reason Medicare May Not Pay: (F) Estimated Cost:

WHAT YOU NEED TO DO NOW: x x x

Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the (D)_____________listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

(G) OPTIONS:

Check only one box. We cannot choose a box for you.

ܻ OPTION 1. I want the (D)__________ listed above. You may ask to be paid now, but I also I want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. ܻ OPTION 2. I want the (D)__________ listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. ܻ OPTION 3. I don’t want the (D)__________listed above.

I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. (H) Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. (I) Signature: (J) Date: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/08)

96

Form Approved OMB No. 0938-0566

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Notice of Exclusions from Medicare Benefits A Notice of Exclusions from Medicare Benefits (NEMBs) allows providers to alert Medicare beneficiaries in advance that Medicare does not cover certain items and services because the item or service does not meet the definition of a benefit, or because the item or service is specifically excluded by law. NEMBs notify the Medicare beneficiary that they will be responsible for paying the healthcare provider for the service and provides the beneficiary with an estimate of the cost of the excluded services.

NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB) There are items and services for which Medicare will not pay. x Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits. Some items and services are not Medicare benefits and Medicare will not pay for them. x When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it, personally or through any other insurance that you may have. The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you will have to pay for them yourself. Before you make a decision, you should read this entire notice carefully. Ask us to explain, if you don’t understand why Medicare won’t pay. Ask us how much these items or services will cost you (Estimated Cost: $_____________). Medicare will not pay for: ________________________________________________ ______________________________________________________________________;

ƒ 1.

Because it does not meet the definition of any Medicare benefit.

Ƒ 2.

Because of the following exclusion * from Medicare benefits:

ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Personal comfort items. ƒ Routine physicals and most tests for screening. Most shots (vaccinations). ƒ Routine eye care, eyeglasses and examinations. Hearing aids and hearing examinations. ƒ Cosmetic surgery. Most outpatient prescription drugs. ƒ Dental care and dentures (in most cases). Orthopedic shoes and foot supports (orthotics). ƒ Routine foot care and flat foot care. Health care received outside of the USA. ƒ Services by immediate relatives. Services required as a result of war. ƒ Services under a physician’s private contract. Services paid for by a governmental entity that is not Medicare. Services for which the patient has no legal obligation to pay. Home health services furnished under a plan of care, if the agency does not submit the claim. Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997. Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need). Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the hospital. Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF) or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF. Services of an assistant at surgery without prior approval from the peer review organization. Outpatient occupational and physical therapy services furnished incident to a physician’s services.

* This is only a general summary of exclusions from Medicare benefits. It is not a legal document. The official Medicare program provisions are contained in relevant laws, regulations, and rulings.

Form No. CMS-20007

(January 2003)

97 IX. Reimbursement Tools & References

Notes

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BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Advanced Beneficiary Notice Advance beneficiary notice, formerly known as the waiver of liability, is a written notice to a Medicare beneficiary that Medicare may not pay for an item or service based upon lack of medical necessity.

Glossary

Allowable The amount of payment an insurance company allows for a particular covered service, which may be less than the actual charge by the physician or supplier. Included in the allowable would be any patient cost-sharing responsibilities (e.g., deductibles, coinsurance). Ambulatory Payment Classification (APC) Medicare’s payment system for hospital outpatient services, implemented as of August 1, 2000, under which hospitals are paid a fixed fee for certain services and payment may be made for multiple APCs in a single patient encounter. Average Sales Price (ASP) The average price of the total number of units of a drug sold by the manufacturer in a quarter. Medicare uses ASP to determine physician office drug payment. Physician office payment for 2007 is based on 106 percent of ASP. Average Wholesale Price (AWP) Listed in Red Book, First DataBank, or other reference source, an estimate of the average amount that wholesalers pay for drugs that is often used by insurance companies as the basis for determining pay reimbursement rates for individual drugs. Appeals Process The process used to formally disagree with any decision about health care services, such as a denial of a request for services or for payment of services received. Carriers Part B contractors that provide administrative services to all beneficiaries, physicians and various suppliers of services (e.g., lab, ambulance, durable medical equipment) that are not associated with an institutional provider (hospital). They represent a given geographic area. Carriers process only those claims paid by Medicare Part B. Case Mix The distribution of patients into categories reflecting differences in severity of illness or resource consumption. Centers for Medicare and Medicaid Services (CMS) Federal agency that oversees Medicare and Medicaid programs. CMS 1450 This form, also known as UB-04, is the claim form used by hospitals and other institutional providers for insurance billing. CMS 1500 This claim form is used to bill Medicare Part B and is used by most other payers to pay or deny professional fees and other services and durable medical equipment. Coinsurance A Percentage of the allowable fee for specific services not paid by the primary payer (such as 20 percent of the allowed amount for an office visit and medication). The coinsurance amount is to be paid by the patient or their supplemental/secondary payer.

99 IX. Reimbursement Tools & References

Copayment (Copay) Patient pays a specified flat amount for specific service (such as $10 for an office visit or $5 for each prescription filled). It does not vary with the cost of the service. Current Procedural Terminology (CPT) A system of terminology and coding developed by the American Medical Association that is used for describing, coding and reporting medical services and procedures. Diagnosis Code A numeric classification descriptive of a disease, injury or cause of death. Medicare requires suppliers to include a diagnosis code or codes on each claim submitted for payment. CMS has adopted the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system for this purpose. Diagnosis-Related Group (DRG) Medicare’s payment system for hospital inpatient services, under which hospitals are paid a fixed fee per patient based on procedures performed and diagnosis upon discharge. Deductible A dollar amount the patient must pay before a benefit plan will begin to contribute towards the cost of treatment. Doughnut Hole The step in a Medicare prescription drug plan in which a beneficiary will pay all of the expenses for eligible drugs. Explanation of Benefits (EOB) A description from the payer showing the claim charges, benefits paid and services rendered by a health care provider for payment. This is sent to the health care provider and patient once a claim has been processed by the payer. Fee Schedule A list of maximum payments for specified Medicare (or other payer) services based on the relative value of the procedure. Fiscal Intermediary (FI) An insurance company contracted by Medicare to process Part A institutional claims. FIs process both hospital inpatient and hospital outpatient claims. Formulary A list of drugs covered by a prescription benefit plan. A formulary may also be referred to as a covered medications list (CML), preferred drug list (PDL), or a select drug list. These drugs are dispensed through participating pharmacies to covered enrollees. Healthcare Common Procedure Coding System (HCPCS) Name given to CPT codes (Level I), alphanumeric codes (Level II) and local codes (Level III) used by Medicare and insurance companies for billing purposes. Most refer to Level II national codes simply as HCPCS codes.

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Health Maintenance Organization (HMO) A healthcare delivery system that provides comprehensive services for subscribing members in a particular geographic area. Most HMO care is provided through a managed network made up of doctors, hospitals and other medical professionals selected by the HMO. HMO enrollees are required to obtain care from this network of providers in order for their care to be covered, except in cases of emergency. All care that members may need is paid for by a single monthly fee, plus nominal copayments. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) The coding system maintained by the National Center for Health Statistics and CMS. It differentiates diagnostic conditions and is used by hospitals, governments, health insurance plans and health care providers around the world. Low Income Subsidy (LIS) A Medicare program to ensure eligible individuals receive prescription benefits. The amount of assistance depends on beneficiary income and resources. Medicare beneficiaries must join a Medicare prescription drug program in order to qualify and may apply through the Social Security Administration or a State Medical Assistance Office. Medicaid Jointly administered program between the federal and state governments to provide insurance coverage to specified groups of low income individuals including the elderly, disabled, children, pregnant women and recipients of other designated federal programs. Medicare Federal program that provides health insurance coverage to qualified elderly and disabled individuals. Medicare Part A The “hospital insurance” portion of Medicare. It covers inpatient hospital care, skilled nursing facility care, some home health agency services and hospice care. Medicare Part B The supplementary or “physician insurance” portion of Medicare. It covers services of physicians/other suppliers, outpatient care, medical equipment and supplies and other medical services not covered by the hospital insurance part of Medicare. Medicare Part C Allows a beneficiary to replace the standard fee-for-service benefits under Parts A and B of Medicare by enrolling in a Medicare sponsored HMO or PPO. Managed care plans may administer the program differently than the rest of the Medicare program. For example, they may have lower co-insurance payments or have prescription drug benefits. Medicare Part D Medicare insurance for oral and self-administered prescription drugs that covers both brand-name and generic medications at participating pharmacies. Modifier Two-digit numeric or alpha code used with another code to indicate that a service or procedure has been altered.

101 IX. Reimbursement Tools & References

National Coverage Decision (NCD) A medical policy decision regarding coverage that applies to all Medicare carriers and intermediaries. In most cases, these decisions supersede decisions made at a local level. National Drug Code (NDC) A unique identifier assigned to individual drugs by the Food and Drug Administration (FDA) and the manufacturer. Prior Authorization Provider Request for a payer to review and approve services, prescriptions or supplies for medical necessity prior to the services, prescriptions or supplies being provided. Prior authorization may be obtained via fax, phone or written request as outlined by the payer. Private Payer A commercial insurance company. Quantity Limit (QL) A management tool designed to limit the amount of a medication a patient may receive per prescription or for a defined period of time. For example, many benefit plans limit the quantity of certain drugs a patient can receive over a one-month period. Any quantity over this limit would not be covered by the benefit plan. A patient or healthcare provider may request an exception to these limits. Skilled Nursing Facility (SNF) An institution that offers nursing services similar to those available in a hospital to aid recuperation of those who are seriously ill. Distinguished from intermediate care and custodial care, which may meet some minor medical needs but are intended primarily to support elderly and disabled individuals in the tasks of daily living. Social Security Administration (SSA) An agency of the Department of Health and Human Services (HHS), established by the Social Security law, which provides retirement, survivor, disability and Medicare benefits. Medicare Part B beneficiaries enroll here. Step Therapy A utilization tool a benefit plan may use to require a patient first try certain drugs to treat a specific medical condition before the plan will cover another drug for that condition. Usual, Customary and Reasonable (UCR) An amount paid by a health plan based on a combination of the physician’s usual fee, the customary fee charged by such specialty physicians in a specific locality and the insurance company’s determination of the reasonable fee for the service. Utilization Review The process of examining healthcare services to measure medical necessity, quality of patient care and the appropriateness of care to identify overuse or ineffective outcomes. Wholesale Acquisition Cost (WAC) The list price for drug wholesalers and distributors that does not include any rebates, discounts or other price concessions offered by the drug manufacturer.

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State Medicaid Contact Information State

Provider Services Phone Number

Website

Alabama

(800) 727-7848

http://www.medicaid.state.al.us/

Alaska

(907) 644-6800

http://www.hss.state.ak.us/dhcs/Medicaid

Arizona

(800) 654-8713

http://www.ahcccs.state.az.us

Arkansas

(501) 376-2211

https://209.12.159.21/

California

(800) 541-5555

http://www.medi-cal.ca.gov/

Colorado

(800) 237-0757

http://www.chcpf.state.co.us

Connecticut

(800) 842-8440

http://www.ctmedicalprogram.com/

Delaware

(800) 999-3371

http://www.dmap.state.de.us

Florida

(800) 289-7799

http://floridamedicaid.acs-inc.com

Georgia

(800) 766-4456

http://dch.georgia.gov

Hawaii

(800) 333-0263

http://www.state.hi.us/dhs/

Idaho

(800) 685-3757

http://www.healthandwelfare.idaho.gov

Illinois

(217) 782-0538

http://www.hfs.illinois.gov/medical/

Indiana

(800) 577-1278

http://www.indianamedicaid.com

Iowa

(800) 338-7909

http://www.dhs.state.ia.us

Kansas

(800) 933 6593

http://www.srskansas.org/services/HCP_index.htm

Kentucky

(800) 807-1232

http://chfs.ky.gov/dms

Louisiana

(800) 473-2783

http://www.dhh.state.la.us/offices/?ID=92

Maine

http://www.maine.gov/dhhs/bms/

Maryland

(800) 321-5557 option 9 (800) 445-1159

Massachusetts

(800) 841-2900

Michigan

(888) 696-3510

http://www.mass.gov/?pageID=eohhs2agencylanding&L=4 &L0=Home&L1=Government&L2=Departments+and+Divi sions&L3=MassHealth&sid=Eeohhs2 http://www.michigan.gov/mdch

Minnesota

(800) 366-5411

http://www.dhs.state.mn.us

Mississippi

(800) 884-3222

http://www.dom.state.ms.us/

Missouri

(573) 751-3221

http://www.dss.mo.gov/

Montana

(800) 624-3958

http://www.dphhs.mt.gov

Nebraska

(402) 471-3121

http://www.hhs.state.ne.us/med/medindex.htm

Nevada

(775) 684-3700

http://dhcfp.state.nv.us/

New Hampshire

(800) 423-8303

http://www.dhhs.state.nh.us/dhhs/medicaidprogram

New Jersey

(800) 356-1561

http://www.state.nj.us/humanservices/dmahs

New Mexico

(888) 997-2583

http://www.hsd.state.nm.us/mad

New York

(800) 343-9000

http://www.health.state.ny.us/health_care/medicaid

North Carolina

(800) 688-6696

http://www.dhhs.state.nc.us/dma/

North Dakota

(800) 472-2622

http://www.nd.gov/humanservices/

http://www.dhmh.state.md.us/mma/mmahome.html

103 IX. Reimbursement Tools & References

State Medicaid Contact Information (continued)

104

State

Provider Services Phone Number

Website

Ohio

(800) 686-1516

http://jfs.ohio.gov/ohp/

Oklahoma

(800) 522-0114

http://www.ohca.state.ok.us/

Oregon

(503) 945-5772

http://www.oregon.gov/DHS/healthplan

Pennsylvania

(800) 537-8862

http://www.dpw.state.pa.us/omap

Rhode Island

(800) 964-6211

http://www.dhs.state.ri.us

South Carolina

(803) 898-2660

http://www.dhhs.state.sc.us

South Dakota

(605) 773-3495

http://dss.sd.gov/

Tennessee

(800) 852-2683

http://www.state.tn.us/tenncare/

Texas

(800) 925-9126

http://www.tmhp.com

Utah

(800) 662-9651

http://hlunix.hl.state.ut.us/medicaid

Vermont

(802) 878-7871

http://www.ovha.state.vt.us/

Virginia

(800) 552-8627

http://165.176.249.159/

Washington

(800) 562-3022

http://fortress.wa.gov/dshs/maa/

Washington, D.C.

(866) 752-9233

West Virginia

(888) 483-0793

http://www.acs-gcro.com/Medicaid_Accounts/ WashingtonDC_Medicaid/washingtondc_medicaid.htm http://www.wvdhhr.org/bms/

Wisconsin

(800) 947-9627

http://www.dhfs.state.wi.us/medicaid/

Wyoming

(800) 251-1268

http://wyequalitycare.acs-inc.com/

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION Glossary

State Department of Insurance Contact Information State

Phone Number(s)

Website

Alabama

(334) 269-3550

http://www.aldoi.gov/

Alaska

(907) 465-2515 (907) 269-7900 Phoenix Area (602) 364-2499

http://www.dced.state.ak.us/insurance/

Arizona

http://www.id.state.az.us/

Tucson Area (520) 628-6370

Arkansas California Colorado

Statewide (800) 325-2548 (501) 371-2600 (800) 282-9134 (800) 92-4357 (213) 897-8921 (303) 894-7499 (303) 894-7490

http://insurance.arkansas.gov/ http://www.insurance.ca.gov/ http://www.dora.state.co.us/insurance/

(800) 930-3745 http://www.ct.gov/cid/site/default.asp

Delaware

(860) 297-3800 (800) 203-3447 (302) 674-7300

Florida

(850) 413-3140

http://www.floir.com/

Georgia

(404) 656-2070

http://www.gainsurance.org/

Hawaii

(808) 586-2790 (808) 586-2799 (208) 334-4250

http://www.hawaii.gov/dcca/areas/ins

http://www.idfpr.com/DOI/default2.asp

Indiana

(217) 782-4515 (312) 814-2420 (317) 232-2395

Iowa

(515) 281-5705

http://www.iid.state.ia.us/

Kansas

(800) 432-2484

http://www.ksinsurance.org/

Kentucky

(800) 595-6053

http://doi.ppr.ky.gov/kentucky/

Louisiana

(800) 259-5300 (800) 259-5301

http://www.ldi.la.gov/

Connecticut

Idaho Illinois

Maine Maryland Massachusetts

Michigan

(225) 342-5900 (225) 342-0895 (207) 624-8475 (410) 468-2000 (800) 492-6116 (617) 521-7794 (617) 521-7490 (517) 373-0220

http://www.delawareinsurance.gov/

http://www.doi.state.id.us/

http://www.in.gov/idoi/

http://www.maine.gov/pfr/insurance/ http://www.mdinsurance.state.md.us/ www.mass.gov Go to Home › Government › Our Agencies and Divisions › and select Department of Insurance http://www.michigan.gov/cis/0,1607,7-154-10555---,00.html

105 IX. Reimbursement Tools & References

State Department of Insurance Contact Information (continued) State

Phone Number(s)

Minnesota

(651) 296-4026

Mississippi

(601) 359-3569

http://www.state.mn.us/portal/mn/jsp/ content.do?subchannel=-536881551&id=536881351&agency=Commerce http://www.doi.state.ms.us/

Missouri

(573) 751-2640

http://insurance.mo.gov/

Montana

(800) 332-6148

http://sao.mt.gov/insurance/index.asp

Nebraska

(402) 471-2201 (877) 564-7323 (775) 687-4270 (702) 486-4009 (603) 271-7973

http://www.doi.ne.gov/

http://www.nj.gov/dobi/insmnu.shtml

New Mexico

(800) 446-7467 (609) 292-5360 (888) 427-5772

New York

(800) 342-3736

http://www.ins.state.ny.us/

North Carolina

(800) 546-5664 (919) 807-6750 (701) 328-2440 (800) 247-0560 (800) 686-1526

http://www.ncdoi.com/

http://www.oid.state.ok.us/

Oregon

(800) 522-0071 (405) 521-2828 (503) 947-7980

Pennsylvania

(877) 881-6388

http://www.ins.state.pa.us/ins/site/default.asp

Rhode Island

(401) 222-2246

http://www.dbr.state.ri.us/

South Carolina

(803) 737-6227

https://www.doi.sc.gov/

South Dakota

(605) 773-3563

http://www.state.sd.us/drr2/reg/insurance/

Tennessee

(615) 741-2241

http://www.state.tn.us/commerce/

Texas

(800) 252-3439

http://www.tdi.state.tx.us/

Utah

(801) 538-3800

http://www.insurance.utah.gov/

Vermont

(800) 964-1784

http://www.bishca.state.vt.us/InsurDiv/insur_index.htm

Virginia

(877) 310-6560

http://www.scc.virginia.gov/division/boi/

Washington

(800) 562-6900

http://www.insurance.wa.gov/

Washington, D.C.

(202) 727-1000

http://disb.dc.gov

West Virginia

(304) 558-3386

http://www.wvinsurance.gov/

Wisconsin

(800) 236-8517

http://oci.wi.gov/

Wyoming

(800) 438-5768

http://insurance.state.wy.us/

Nevada New Hampshire New Jersey

North Dakota Ohio Oklahoma

106

Website

http://www.doi.state.nv.us/ http://www.nh.gov/insurance/

http://www.nmprc.state.nm.us/id.htm

http://www.nd.gov/ndins/ http://www.ohioinsurance.gov/

http://insurance.oregon.gov/

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Medicare Carriers Contact Information Geographic Jurisdiction

Phone Number

Website

NGS (AdminaStar Federal)

IN, KY

(866) 250-5665

http://www.adminastar.com/index.html

NGS (Empire Medicare Services)

NY (Downstate), NJ

(888) 855-4346

http://www.empiremedicare.com/provider. cfm

Wisconsin Physicians Service (WPS)

IL

(866) 234-7340

http://www.wpsmedicare.com/

WI

(866) 359-1599

MN

(866) 359-1598

MI

(866) 234-7331

Upstate Medicare Division (UMD)

NY (Upstate)

(877) 567-7173

http://www.umd.nycpic.com/

TrailBlazer Health Enterprises

TX

(866) 211-5708

http://www.trailblazerhealth.com/

MD

(888) 803-4695

DE

(888) 205-6833

DC

(888) 205-6833

VA

(866) 717-0010

Pinnacle Medicare Services

AR

(866) 345-0274

http://www.arkmedicare.com/

Pinnacle Medicare Services

LA

(866) 567-8419

http://www.lamedicare.com/

Pinnacle Medicare Services

MO (Eastern)

(866) 736-0799

http://www.momedicare.com/

Noridian Administrative Services

AK, HI, NV, OR, WA

(800) 933-0614

https://www.noridianmedicare.com/

First Coast Services Options (FCSO)

FL

(888) 664-4112

http://www.floridamedicare.com/

CT

(888) 760-6950

http://www.connecticutmedicare.com/

GHI Medicare

NY (Queens)

(877) 868-7965

http://www.ghimedicare.com/

NHIC2

MA

(877) 567-3130

http://www.medicarenhic.com/

ME

(877) 567-3129

VT

(866) 539-5595

NH

(866) 539-5595

Southern CA

(866) 502-9054

Northern CA

(877) 591-1587

Highmark Medicare Services

PA

(866) 488-0548

http://www.highmarkmedicareservices.com/

Cigna Government Services

TN

(866) 824-8572

http://www.cignagovernmentservices.com/

NC

(866) 655-7996

ID

(866) 824-8593

Contractor

107 IX. Reimbursement Tools & References

Medicare Carriers Contact Information (continued) Contractor

Geographic Jurisdiction

Phone Number

Website

Palmetto GBA

SC

(866) 238-9654

http://www.palmettogba.com/index.html

WV, OH

(877) 567-9232

AL

(866) 539-5598

GA

(877) 567-7271

MS

(866) 419-9454

PR, VI

(877) 715-1921

Cahaba GBA

Triple-S, Inc.

108

https://www.cahabagba.com/

http://www.triples-med.org/webmedicare/

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Medicare Fiscal Intermediaries Contact Information* Geographic Jurisdiction

Phone Number

Website

NGS (AdminaStar Federal)

IL, IN, KY, OH

(866) 419-9457

http://www.adminastar.com/index.html

NGS (Empire Medicare Services)

NY, CT, DE

(888) 855-4346

http://www.empiremedicare.com/provider.cfm

NGS (Anthem Health Plans of NH)

NH, VT

(866) 539-5593

http://www.ahpnhmedicare.com/default.asp

NGS (Associated Hospital Services)

ME, MA

(866) 539-5593

http://www.ahsmedicare.com/default.asp

NGS (United Government Services)

CA, GU, HI, MI, NV, Northern Mariana Islands, VA, WV, WI

(800) 921-1919

http://www.ugsmedicare.com/index.asp

TrailBlazer Health

CO, NM, TX

(888) 763-9836

http://www.trailblazerhealth.com/

First Coast Service Options (FCSO)

FL

(888) 664-4112

http://www.floridamedicare.com/Part_A/index.asp

Highmark Medicare Services

PA, MD, DC

(866) 488-0545

http://www.highmarkmedicareservices.com

Cahaba GBA

AL, IA

(866) 539-5598

https://www.cahabagba.com/

Contractor

(877) 567-3092 (877) 567-3092 Pinnacle Medicare Services

AR

(877) 726-1711

http://www.arkmedicare.com/

Pinnacle Medicare Services

RI

(866) 339-3714

http://www.rimedicare.com/

Noridian Administrative Services

AK, ID, MN, OR, WA

(877) 908-8437

https://www.noridianmedicare.com/

BlueCross and BlueShield of GA

GA

(877) 567-3095

http://www.georgiamedicare.com/

Palmetto GBA

SC, NC

(877) 567-9249

http://www.palmettogba.com/

Riverbend GBA

NJ, TN

(877) 296-6189

http://www.rgbagov.com/

TriSpan Health Services

LA, MS, MO

(877) 567-3097

http://www.trispan.com/

COSVI

PR, VI

(877) 908-8433

http://cosvimedicare.com/

* As of January 1, 2007, AdminaStar Federal, Empire, United Government Services, Anthem Health Plans of NH, and Associated Hospital Services merged to form National Government Services (NGS).

109 IX. Reimbursement Tools & References

Medicare Part A/B MACs Contact Information Part A/B MAC

Jurisdiction

Noridian Administrative Services

3

TrailBlazer Health Enterprises

4

Wisconsin Physician Service (WPS)

Geographic Jurisdiction AZ, MT, ND, SD, UT, WY (Part A and B) -CO (Part B) -NM (Part B) -OK (Part A and Part B)

5

-IA (Part B) -KS (Part A and B) -NE (Part A and B) -MO Western (Part B)

Phone Number

Website

(800) 933-0614

https://www. noridianmedicare.com/ macj3b/

(866) 640-9202

http://www. trailblazerhealth.com/J4/

Part A (CO/NM/OK)

(866) 280-6520

Part B (CO/NM/OK)

(866)518-3285 Part A (866)503-3807

http://www. wpsmedicare.com/mac/ index.shtml

Part B

Manufacturer Sponsored Patient Assistance Programs Contact Information Many drug manufacturers offer assistance to patients who cannot afford their osteoporosis treatments. The following table provides a list of manufacturer-sponsored drug programs and the phone number for each program. Please contact the program directly to find out what support is available and how a patient may apply for help. Program Name

Manufacturer

Drug

Phone Number

Lilly Cares

Eli Lilly

Evista®

(800) 545-6962

Forteo®

(866) 436-7836

Lilly Forteo Customer Care Program

110

Merck Patient Assistance Program

Merck

Fosamax®

(800) 727-5400

Novartis Pharmaceuticals Corporation's Patient Assistance Program

Novartis

Miacalcin®

(800) 277-2254

Reclast®

(800) 833-0166

Procter & Gamble Patient Assistance Program

Procter & Gamble

Actonel®

(800) 830-9049

Roche Patient Assistance Program

Roche

Boniva®

(888) 587-9438

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Comprehensive List of Codes Relating to Osteoporosis Prevention, Diagnosis, and Treatment ICD-9-CM Diagnosis Codes for Osteoporosis and Related Conditions ICD-9-CM Diagnosis Codes and Descriptions Osteoporosis 733.00 733.01 733.02 733.03 733.09 V17.81 733.90 793.7

Unspecified osteoporosis Senile osteoporosis (Postmenopausal) Idiopathic osteoporosis Disuse osteoporosis Other osteoporosis (drug-induced) Family history of, Osteoporosis Disorder of bone and cartilage, unspecified Nonspecific abnormal findings on radiological and other examination of musculoskeletal system

Pathologic Fracture 733.10 733.11 733.12 733.13 733.14 733.15 733.16 733.19 V54.20-V54.29

Pathologic fracture, unspecified site Pathologic fracture of humerus Pathologic fracture of distal radius and ulna (Wrist NOS) Pathologic fracture of vertebrae (Collapse of vertebrae N OS) Pathologic fracture of neck of femur (Femur/Hip NOS) Pathologic fracture of other specified part of femur Pathologic fracture of tibia and fibula (Ankle NOS) Pathologic fracture of other specified site Aftercare for healing pathologic fracture (Site specific)

Fracture of Neck and Trunk 805.00-829.1

Fracture of Neck and Trunk (site specific)

Diseases of Endocrine Glands 252.0x 255.0 256.2 256.31 256.39 259.3 268.2 268.9 627.x V07.4 V49.81

Hyperparathyroidism Cushing's syndrome Postablative ovarian failure Premature menopause (permanent cessation of ovarian function) Other ovarian failure Ectopic hormone secretion, not elsewhere classified (hyperparathyroidism) Osteomalacia, unspecified Unspecified vitamin D deficiency Menopausal and postmenopausal disorders Hormone replacement therapy (postmenopausal) Asymptomatic postmenopausal status (age-related) (natural)

111 IX. Reimbursement Tools & References

Diagnostic Tests CPT and ICD-9-CM Procedure Codes for Bone Densitometry by DEXA CPT/ICD-9-CM Codes and Descriptions DXA CPT category I codes are used by physician offices and hospital outpatient clinics

77080

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine)

77081

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)

77082

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment

0028T

Dual energy x-ray absorptiometry (DXA) body composition study, one or more sites

CPT category III codes are used by physician offices and hospital outpatient clinics

Bone mineral density studies

ICD-9-CM procedure codes are used by inpatient hospital facilities

88.98

Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

PT and ICD-9-CM Procedure Codes for Bone Densitometry by Other X-Ray Absorptiometry CPT/HCPCS/ICD-9-CM Codes and Descriptions Other X-ray Absorptiometry 77083

Radiographic absorptiometry (e.g. photodensitometry, radiogrammetry), 1 or more sites

CPT category I codes are used by physician offices and hospital outpatient clinics

G0130

Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g. radius, wrist, heel)

HCPCS codes are used by physician offices and hospital outpatient clinics

88.98

Bone mineral density studies

ICD-9-CM procedure codes are used by hospital facilities

Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

112

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

CPT and ICD-9-CM Procedure Codes for Bone Densitometry by Photon Absorptiometry CPT/ICD-9-CM Codes and Descriptions Photon Absorptiometry 78350

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry

78351

Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

88.98

Bone mineral density studies

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital facilities

Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

CPT and ICD-9-CM Procedure Codes for Bone Densitometry by Computed Tomography CPT/ICD-9-CM Procedure Codes and Descriptions Computed Tomography (CT) 77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g. spine, hips, pelvis) (QCT)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g. wrist, radius, heel) (pQCT)

88.98

Bone mineral density studies

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital facilities

Dual photon absorptiometry Quantitative computed tomography (CT) studies Radiographic densitometry Single photon absorptiometry

CPT and ICD-9-CM Procedure Codes for Bone Sonometry By Ultrasound CPT/HCPCS Codes and Descriptions Ultrasound 76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method (QUS)

CPT category I codes are used by physician offices and hospital outpatient clinics

88.79

Other diagnostic ultrasound

ICD-9-CM Procedure codes are used by hospital facilities

113 IX. Reimbursement Tools & References

CPT and ICD-9-CM Procedure Codes for Bone Mass Measurement By Biopsy CPT and ICD-9-CM Procedure Codes and Descriptions

114

20220

Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs)

20225

Biopsy, bone, trocar, or needle; deep (e.g., vertebral body, femur)

20240

Biopsy, bone, open; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur)

20245

Biopsy, bone, open; deep (e.g., humerus, ischium, femur)

38221

Bone marrow; biopsy, needle or trocar

00190

Anesthesia for procedures on facial bones or skull; not otherwise specified

01112

Anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest

01120

Anesthesia for procedures on bony pelvis

01220

Anesthesia for all closed procedures involving upper twothirds of femur

01340

Anesthesia for all closed procedures on lower one-third of femur

01730

Anesthesia for all closed procedures on humerus and elbow

77.41

Biopsy of scapula, clavicle, and thorax (ribs and sternum)

77.45

Biopsy of femur

77.49

Biopsy of other bone, except facial bones

44.31

Bone marrow; biopsy

CPT category I codes are used by physician offices and hospital outpatient clinics

ICD-9-CM procedure codes are used by hospital inpatient facilities

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

ICD-9-CM Covered Diagnosis Codes for Collagen Cross Links ICD-9-CM Diagnosis Codes and Descriptions Osteoporosis 242.00-242.91

Thyrotoxicosis

245.2

Chronic lymphocytic thyroiditis (only if thyrotoxic)

246.9

Unspecified disorder of thyroid

252.00-252.02, 252.08

Hyperparathyroidism

256.2

Postablative ovarian failure

256.31-256.39

Other ovarian failure

256.8-256.9

Ovarian dysfunction

268.9

Unspecified vitamin D deficiency

269.3

Mineral deficiency, not elsewhere classified

627.x

Menopausal and postmenopausal disorders

731.0

Osteitis deformans without mention of bone tumor (Paget’s disease of bone)

733.00-733.09

Osteoporosis

733.10-733.19

Pathological fracture

733.90

Disorder of bone and cartilage, unspecified

805.8

Fracture of vertebral column without mention of spiral cord injury, unspecified, closed

V58.65

Long-term (current) use of steroids

V58.69

Long-term (current) use of other medications

Collagen cross links are reported with CPT code 82523 by physician offices and hospital outpatient clinics. 82523, Collagen cross links, any method (Biochemical markers).

Advanced Beneficiary Notice (ABN) Modifiers Modifier and Descriptions

Signed ABN Required

GA

Waiver of liability statement on file

Yes

GX

Service not covered by Medicare

Not necessary

GY

Statutorily excluded

Not necessary

GZ

Expected to be denied as not reasonable and necessary

No – Attach this modifier if an ABN was not signed

Diagnostic Test Modifiers Modifier and Descriptions

Provider

TC

Technical component only

Hospital facility

26

Professional component only

Physician

No Modifier

Global (G) concept – both technical and professional

Physician

115 IX. Reimbursement Tools & References

INPATIENT PHYSICAL AND OCCUPATIONAL THERAPY ICD-9-CM Diagnosis V-Codes for Osteoporosis V - Code

Description

V17.80

Other musculoskeletal diagnosis

V17.81

Family history of Osteoporosis

V54

Describes Orthopedic aftercare

V54.20-V54.29

Specifically address pathologic fractures of arm, hip, vertebrae

PT Evaluation and Testing ICD-9-CM Procedure Codes Code

Description

Physical therapy, respiratory therapy, rehabilitation, and related procedures 93.01

Functional evaluation

93.05

Range of motion testing

PT Management ICD-9-CM Procedure Codes

116

Code

Description

93.11

Physical therapy exercises - Assisting exercises

93.14

Physical therapy exercises - Training in joint movements

93.15

Physical therapy exercises - Mobilization of spine

93.16

Physical therapy exercises - Mobilization of other joints

93.17

Physical therapy exercises - Other passive musculoskeletal exercise

93.18

Physical therapy exercises - Breathing exercise

93.19

Physical therapy exercises - Exercise, not elsewhere classified

93.21

Other physical therapy musculoskeletal manipulation - Manual and mechanical traction

93.22

Other physical therapy musculoskeletal manipulation - Ambulation and gait training

93.42

Skeletal traction and other traction - Other spinal traction

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

OT Related ICD-9-CM Procedure Codes Code

Description

Other immobilization, pressure, and attention to wound 93.51

Application of plaster jacket

93.52

Application of neck support

93.53

Application of other cast

93.54

Application of splint

Other rehabilitation therapy 93.83

Occupational therapy (daily living activities therapy)

93.89

Rehabilitation, not elsewhere classified

Revenue Codes Related to Osteoporosis Hospitalization Resources Inpatient Revenue Description Codes 0420

General Classification - PT

0421

Visit Charge - PT

0422

Hourly Charge - PT

0423

Group Rate - PT

0424

Evaluation or Re-Evaluation - PT

0429

Other Physical Therapy

0430

General Classification - OT

0431

Visit Charge - OT

0432

Hourly Charge - OT

0433

Group Rate - OT

0434

Evaluation or Re-Evaluation - OT

0439

Other Occupational Therapy

117 IX. Reimbursement Tools & References

OUTPATIENT PHYSICAL AND OCCUPATIONAL THERAPY CPT Evaluation Codes for PT and OT Code

Description

97001

Physical Therapy Evaluation

97002

Physical Therapy Re-evaluation

97003

Occupational Therapy Evaluation

97004

Occupational Therapy Re-evaluation

CPT Modality Codes for PT Code

Description

97010

Application of a modality to one or more areas; hot or cold packs

97014

Electrical stimulation (unattended)

97022

Whirlpool

CPT Codes for Modalities Requiring Constant Attendance Code

Description

97032

Application of a modality to one or more area; electrical stimulation (manual), each 15 minutes

97033

Iontophoresis, each 15 minutes

CPT Therapeutic Procedure Codes for PT

118

Code

Description

97110

Therapeutic Procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112

Therapeutic Procedure, neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, each 15 minutes

97116

Therapeutic Procedure, gait training (includes stair climbing), each 15 minutes

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

CPT Therapeutic Procedure Codes for OT Code

Description

97530

Therapeutic Services, direct (one-on-one) patient contract by the provider (use of dynamic activities to improve functional performance, each 15 minutes

97535

Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97542

Wheelchair management (e.g., assessment, fitting, training) each 15 minutes

Revenue Codes Associated with Osteoporosis-Related Hospital Procedures Revenue Codes

Description

0420

General Classification - PT

0421

Visit Charge - PT

0422

Hourly Charge - PT

0423

Group Rate - PT

0424

Evaluation or Re-Evaluation - PT

0429

Other Physical Therapy

0430

General Classification - OT

0431

Visit Charge - OT

0432

Hourly Charge - OT

0433

Group Rate - OT

0434

Evaluation or Re-Evaluation - OT

0439

Other Occupational Therapy

CPT Consultation Codes Code

Description

99241

Office consultation; problem-focused history

99242

Office consultation; expanded problem-focused history

99243

Office consultation; a detailed history

99244

Office consultation; a comprehensive history; 60 minutes

119 IX. Reimbursement Tools & References

ORTHOPEDIC – INPATIENT ICD-9-CM Diagnosis V-Codes for Osteoporosis V - Code

Description

V17.80

Other musculoskeletal diagnosis

V17.81

Family history of Osteoporosis

V54

Describes Orthopedic aftercare

V54.20-V54.29

Specifically address pathologic fractures of arm, hip, vertebrae

ICD-9-CM Procedure Codes for Osteoporosis-Related Orthopedic Procedures

120

ICD-9-CM Procedure Code

Description

03.53

Repair of vertebral fracture

93.51-93.59

Other immobilization, pressure, and attention to wound

97.88

Removal of external mobilization device

97.11-97.14

Nonoperative replacement of musculoskeletal and integumentary system appliance

93.41-93.46

Skeletal traction and other traction

79.0-79.9

Reduction of fracture or dislocation

78.8

Diagnostic procedures on bone, not elsewhere classified

88.94

Magnetic resonance imaging (MRI) of musculoskeletal

87.21-87.29, 87.43, 88.21-88.33

Skeletal X-ray

81.40

Repair of hip, not elsewhere classified

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

Revenue Codes Associated with Osteoporosis-Related Hospitalization Resources Revenue Codes

Description

0100

All inclusive Room and Board

0110

General Classification Room and Board - Private

0120

General Classification Room and Board - Semi-Private

0250

General Classification - Pharmacy

0270

General Classification Med. Surg. Supplies

0279

Other Supplies/Devices

0300

General Classification Laboratory

0320

General Classification DX X-Ray

0360

General Classification - OR Services

0370

General Classification Anesthesia

0450

General Classification Emergency Room

0700

General Classification Cast Room

121 IX. Reimbursement Tools & References

ORTHOPEDIC - OUTPATIENT CPT Codes for Vertebroplasty and Kyphoplasty Code

Description

22520

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic

22521

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar

22522

Each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

22523

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation ( e.g., kyphoplasty); thoracic

22524

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); lumbar

22525

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); Each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)

77002

Flouroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)

77003

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction

CPT Evaluation and Management (Office Visit) Codes Code New Patient

Description

99201

Office or other outpatient visit; problem focused history

99202

Office or other outpatient visit; expanded problem focused history

99203

Office or other outpatient visit; detailed history

99204

Office or other outpatient visit; comprehensive history - 45 minutes

99205

Office or other outpatient visit; comprehensive history - 60 minutes

Established Patient

122

99211

Office or other outpatient visit; 5 minutes

99212

Office or other outpatient visit; problem focused history

99213

Office or other outpatient visit; expanded problem focused history

99214

Office or other outpatient visit; detailed history

99215

Office or other outpatient visit; comprehensive history

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

PHYSICIAN ADMINISTERED DRUGS HCPCS Coding for Physician-Administered Drugs for Osteoporosis Brand name

Description

Route of administration

HCPCS code

Boniva®

Injection, ibandronate sodium, 1mg

IV, 3mg every 3 months

J1740

Miacalcin®

Injection, calcitonin salmon, up to 400 units

IM or SC, 100 units, every other day

J0630

Reclast®

Injection, zoledronic acid (Reclast), 1mg

IV, once a year

J3488

CPT Drug Administration Coding CPT Code

Description

90765

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

90772

Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

90774

Intravenous push, single or initial substance/drug

90779

Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion

CPT Evaluation and Management (Office Visit) Codes Code

Description

New Patient 99201

Office or other outpatient visit; problem-focused history

99202

Office or other outpatient visit; expanded problem-focused history

99203

Office or other outpatient visit; detailed history

99204

Office or other outpatient visit; comprehensive history - 45 minutes

99205

Office or other outpatient visit; comprehensive history - 60 minutes

Established Patient 99211

Office or other outpatient visit; 5 minutes

99212

Office or other outpatient visit; problem-focused history

99213

Office or other outpatient visit; expanded problem-focused history

99214

Office or other outpatient visit; detailed history

99215

Office or other outpatient visit; comprehensive history

123 IX. Reimbursement Tools & References

National Drug Codes for Physician-Administered Drugs for Osteoporosis 10-Digit Format Boniva®

0004-0188-09

Calcimar®

0078-0149-23

Reclast®

0078-0435-61

11-Digit Format 00040-0188-09

Boniva® Calcimar

00780-0149-23

Reclast

00078-0435-61

®

®

Revenue Codes for Drugs Used to Treat Osteoporosis in the Hospital Setting

124

Revenue Code

Description

025X

Pharmacy

026X

IV Therapy

0636

Drugs requiring detailed coding

BILLING & REIMBURSEMENT GUIDE n NATIONAL OSTEPOROSIS FOUNDATION

­­­Section 10 Patient Tools

125 X. PATIENT TOOLS

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PAYING FOR YOUR OSTEOPOROSIS MEDICATIONS:

What You Need to Know

H

ow much your insurance company pays for your osteoporosis medication depends on the type of insurance plan you have. Osteoporosis medications require a prescription from your healthcare provider. They include oral medications that patients take by mouth, such as tablets and liquids. They also include injections that patients give themselves at home as well as nasal sprays and patches. The different types of osteoporosis medications are listed in the table below. You may pay a certain amount of money or copay for these medications. Most insurance companies have a formulary that lists the prescription medications that your insurance company has approved to pay either in part or in full. Once you understand how much your insurance will pay, you will then know what you need to pay for the medications you use to prevent or treat osteoporosis. Below is a list of medications your doctor may prescribe for you to help prevent or treat osteoporosis. Medications to Prevent and Treat Osteoporosis

Drug

Brand name

Type

Alendronate

Fosamax® or Fosamax® plus D

by mouth

Ibandronate

Boniva®

by mouth, IV infusion

Risedronate

Actonel® or Actonel® with Calcium

by mouth

Calcitonin

Miacalcin® or Fortical®

injection or nasal spray

Estrogen Therapy (ET)/ Hormone Therapy (HT)

Multiple brands available

by mouth, skin patch, vaginal ring, cream, injection, etc.

Parathyroid hormone [PTH(1-34), teriparatide]

Forteo®

injection

Raloxifene

Evista®

by mouth

Zoledronic acid

Reclast®

IV infusion

Understanding the Medicare Part D Prescription Drug Benefit Medicare pays for prescription medications through the Medicare Prescription Drug benefit, also called “Part D”. This benefit is available to everyone with Medicare and may help lower the cost of your prescription drugs. If you want to have Part D drug benefits, you must sign up for a Medicare prescription drug plan by choosing the one that works best for you. This handout will help you understand how the program works and where you can go for help.

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Paying for Your Osteoporosis Medications:

What You Need to Know Enrolling in a Medicare Prescription Drug Plan You can change your choice of plans if you are already enrolled in a Part D plan between November 15th and December 31st of each year. You must sign up for Medicare Part D between three months before and three months after your 65th birthday, or between November 15th and December 31st of each year. If you enroll in Medicare Part D outside of this time frame, you may have to pay a higher fee as long as you have Medicare prescription drug coverage. Some people have prescription drug coverage through a union or former employer. If this pays as well or better than Medicare, it is called “creditable coverage.” If you have this type of coverage, make sure your union or employer sends you information on your prescription benefit. This will help you to determine if it qualifies as “creditable coverage.” If you have “creditable coverage,” you can decline Medicare’s prescription drug coverage and not have to pay an extra fee if you enroll later. How to Choose a Medicare Prescription Drug Plan There are different Medicare Part D plans available to you, and each plan is different. How much you will have to pay for your medications will vary depending on which Part D plan you choose. Therefore, before you enroll in a plan, you should make a list of all the prescription drugs you take and how much they cost. You can then compare the plans to decide which one is best for you. Be sure you keep your osteoporosis medications in mind as you review Part D plans. To compare plans, you may:

each plan. The fee you pay for Medicare Part D is an additional fee. In other words, you must pay this fee in addition to the monthly fee you already pay for your Medicare Part B benefits. You may also have an annual deductible. This is the amount you must pay for your medications before Medicare begins to pay for them. You also will have to pay a portion of the cost of your medications. This is called a copayment or coinsurance. Your costs will depend on three things: 1) which plan you choose; 2) the medications you take; and 3) whether you are eligible to receive extra help paying for your costs through a low-income subsidy. For further information on the Medicare Prescription Drug Benefit you may call the Centers for Medicare & Medicaid Services at 1-800-MEDICARE (1-800-6334227) or visit www.medicare.gov on the web.

Part D Low-Income Subsidy (LIS) If you have Medicare and limited income and resources, the Social Security Administration (SSA) may help you pay the costs of your Medicare prescription drug plan. The SSA can also help you find organizations in your community that may help you to enroll in a Medicare prescription drug plan. How to Contact the Social Security Administration (SSA) Telephone

Toll-free, 7 a.m. to 7 p.m., Monday through Friday: 1-800-772-1213

Mail

Social Security Administration

Office of Public Inquiries Windsor Park Building 6401 Security Boulevard Baltimore, MD 21235

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. • Call your State Health Insurance Program (telephone numbers are listed in the Medicare & You Handbook available at www.medicare.gov). • Visit www.medicare.gov on the internet and select “Compare Medicare Prescription Drugs Plans”. If you enroll in a Medicare Part D plan, you will probably pay a monthly fee or “premium” for your prescription drug coverage. This fee is different for 128

Web

http://www.socialsecurity.gov/

Locate your local Social Security Administration office

Call 1-800-772-1213 or use the Social Security Office Locator tool available online. Visit www.socialsecurity.gov, click on “Contact Us” and select “In person”.

Paying for Your Osteoporosis Medications:

What You Need to Know Medications Given by a Healthcare Professional Most insurance companies cover medications given by a healthcare professional in a medical office or hospital. The amount you pay for these types of medications is different from what you might pay for a medication you pick up at the pharmacy. If your doctor prescribes an osteoporosis medication that must be given in a healthcare provider’s office through an intravenous infusion or injection, you should find out how much your health plan pays for this type of medication, as well as how much it will cost you. These medications may include ibandronate (Boniva®) and zoledronic acid (Reclast®) and sometimes Calcitonin (Miacalcin®).

What is Prior Authorization? Your health insurance company may ask that you or your doctor get “prior authorization” before the insurance company will agree to pay for certain treatments or services. By reviewing your condition and the prescribed treatment with you or your doctor, your insurance company can decide if it will pay for the medication. Sometimes, your doctor will call before you receive these treatments to find out if your insurance company needs prior authorization. If you do not know if your insurance plan needs prior authorization, you may call and ask. Each insurance company has its own prior authorization process. Some may ask your doctor to send a letter that explains why the treatment is necessary. Other insurance companies may take the information over the phone or by fax. If you are asking for prior authorization yourself, it is often helpful to have a letter from your doctor telling why they have prescribed the treatment for you. When you call your insurance company to inquire about prior authorization, you will want to ask these questions: • Does my plan require prior authorization for coverage of this service or product? For example, “Do I have to get prior approval for my osteoporosis medication?” or

“Does my plan require prior authorization for physical therapy?” • How do you give prior authorization? Can I give the information to authorize my treatment or does my doctor need to make the request? • What medical information should I include with the prior authorization request? Does my doctor need to write a letter? What paperwork or proof will you need? • Where do I send the information for the prior authorization? Can I have a phone number, fax number, email address, mailing address and/or contact person for prior authorization? • How will I know when a decision has been made? • How long will it take for a decision to be made? When should I follow up on my prior authorization request? • Will I need to file for authorization again after a certain amount of time? Do I follow the same process to have the authorization recertified?

Appealing Insurance Denials When you receive treatment in your doctor’s office or pick up a prescription at the pharmacy, your doctor or pharmacist will submit a claim to your insurance company. If it is denied, you or your doctor may need to call the insurance company. Sometimes your insurance company will not pay for a treatment even if you or your doctor follow the prior authorization or claims submission steps as you were told to do. Often a denial is simply the result of errors or incomplete information being given to the insurance company. In most cases you can simply make the necessary changes and resubmit the claim or prior authorization request to the insurance company. 129

Paying for Your Osteoporosis Medications:

What You Need to Know Though coverage denials can be frustrating, it is important for you to remember that an initial denial is not final and may be changed if you file an appeal. When you file an appeal, you are asking your insurance company to review the denied request. The appeals process varies among health insurance plans, so you will need to call your insurance company to learn the steps you need to take. We have listed some questions below that you will want to ask your insurance company when you call to ask about filing an appeal: • Why was the request denied? If coverage was denied due to an error or incomplete information, ask if you still need to file a formal appeal. • Who must send the appeal (you or your doctor)? • What is the appeals process? What medical documents need to be submitted for an appeal? Is there a specific appeals form required by the insurance company? • How long will it take for the insurance company to process the appeal? • How will I learn when a decision is made? • Who or what department should I follow up with about the status of my appeal? Most insurance plans require that you or your doctor write an appeal letter with information about your

medical history, condition, previous therapies and why a certain medication is being prescribed for you. No matter what type of insurance you have, you have the right to file an appeal.

Prescription Assistance The Partnership for Prescription Assistance (PPA) brings together drug companies, doctors, other health care providers, patient advocacy organizations and community groups to help you get access to the medications you need if you are uninsured and qualify for help. On the PPA website you can find information on over 475 public and private patient assistance programs. PPA will direct you to public or private programs that can best meet your needs. You can also learn how to contact government programs you may qualify for, such as Medicaid or Medicare. If you need assistance or would like additional information on the PPA, contact information is provided below. Telephone

Toll-free at1-888-4PPA-NOW (1-888-477-2669)

Web

www.PPARx.com

Manufacturer Sponsored Patient Assistance Programs Many drug manufacturers offer help to patients who cannot afford to pay for their osteoporosis treatments. The following table provides a list of manufacturer-sponsored drug programs and the phone number for each program. Please call the program directly to find out what support is available and how a you may apply for help.

Program Name Lilly Cares Lilly Forteo Customer Care Program Merck Patient Assistance Program

Manufacturer Eli Lilly Merck

Drug

Phone Number

Evista®

(800)545 6962

Forteo®

(866) 436-7836

Fosamax®

(800) 727-5400

Miacalcin®

(800) 277-2254

Reclast®

(800) 833-0166

Novartis Pharmaceuticals Corporation’s Patient Assistance Program

Novartis

Procter & Gamble Patient Assistance Program

Procter & Gamble

Actonel®

(800) 830-9049

Roche Patient Assistance Program

Roche

Boniva®

(888) 587-9438

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