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CMS Launches Next Phase of New Quality Improvement Program


On July 18, CMS awarded additional contracts as part of a restructuring of the Quality Improvement Organization (QIO) Program to create a new approach to improve care for beneficiaries, families and caregivers. QIOs are private, mostly not-for-profit organizations staffed by doctors and other health care professionals trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care. The new contracts being awarded to fourteen organizations represent the second phase of QIO restructuring. The awardees will work with providers and communities across the country on data-driven quality initiatives. These QIOs will be known as Quality Innovation Network (QIN)-QIOs.

QIN-QIO projects will be based in communities, health care facilities and clinical practices. They will drive quality by providing technical assistance, convening learning and action networks for sharing best practices, collecting and analyzing data for improvement. HHS National Quality Strategy (NQS) and the CMS Quality Strategy provide the framework for the contracts along with the companion, recommendations, and priorities.

Specifically, each QIN-QIO will work on strategic initiatives such as reducing healthcare associated infections, reducing readmissions and medication errors, working with nursing homes to improve care for residents, supporting clinical practices in using interoperable health information technology to enable the exchange of essential health information to improve the coordination of care, promoting prevention activities, reducing cardiac disease and diabetes, reducing health care disparities and improving patient and family engagement. QIN-QIOs will also provide technical assistance for improvement in CMS value based purchasing programs, including the physician value based modifier program.

As a result of the changes, some hospitals and providers will now work with a different QIO than in the past. The new QIN-QIO contracts were competitively awarded. The restructured program will continue to ensure that the entire country participates in strategic initiatives and that local practices are considered. The first phase of the restructuring – which CMS announced on May 9, 2014 –allows two Beneficiary and Family-Centered Care (BFCC) QIO contractors to perform the program’s case review and monitoring activities separate from the quality improvement activities performed by QIN-QIOs. CMS will introduce the program changes with the beginning of its five year, 11th Statement of Work – the QIO contracts cycle – on August 1, 2014.

For more information please visit: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-07-18.html?DLPage=1&DLSort=0&DLSortDir=descending

CPT 90999 for Isolated Ultrafiltration


Recently, Novitas reviewed services reporting Isolated Ultrafiltration for Management of Fluid Overload in Cardiac Disease. Following the review, it was determined that HCPCS code 90999, Unlisted Dialysis Procedure, Inpatient or Outpatient is the most accurate HCPCS code to report for this service.

Effective for dates of service on or after August 14, 2014, claims for ultrafiltration for management of fluid overload in cardiac disease should be reported with HCPCS code 90999. Consistent with the current process for Not Otherwise Classified (NOC) codes, payment for these services will be determined by the Contractor. Please refer to the Local Contractor Pricing Webpage for additional information regarding the determination of fees.

Affordable Care Act "grace period"


Under the Affordable Care Act (ACA), if a patient who receives an advance premium tax credit does not pay his or her health insurance premiums in full, he or she enters a 90-day "grace period." During the first month of the grace period, the patient continues to have health insurance coverage, and the patient's health insurer will pay claims for health care services provided to the patient during that time.  However, if the patient enters the second or third month of the grace period, the health insurer may pend claims for services provided to the patient during that time.  If the patient pays his or her premiums in full before the end of the grace period, the patient retains health insurance coverage for the second and third months of the grace period, and the insurer will pay the pended claims.  But if the patient does not pay his or her health insurance premiums in full before the end of the grace period, the health insurer will not extend coverage for the second or third months of the grace period and will deny claims for services provided during that time.  In this case, a patient is then responsible for paying the entire bill for services rendered during the second and third months.  

Health insurers are required to notify physicians of patients' grace period status. Still, a number of questions concerning the specifics of notification, as well as other issues of concern to physicians, have yet to be addressed.  It is, therefore, important that you find out how your patients' contracted health insurance issuers will provide notice and handle other grace period issues.  It is also vital that your practice proactively take steps to minimize any potential non-payments from health insurers that are due to cancellation of coverage at the end of the grace period.

Reference: http://www.ama-assn.org/ama/pub/advocacy/topics/affordable-care-act/aca-grace-period.page

ICD 9 CM 714.0 Rheumatoid arthritis expands to 190 more specific ICD 10 codes


Rheumatoid arthritis is an Autoimmune disease results in chronic systemic disease principally of joints, manifested by inflammatory changes in articular structures and synovial membranes, atrophy, and loss in bone density. ICD 9 has only one ICD to report this condition whereas ICD 10 expands upto 190 options for reporting RA more specifically.

714.0 Rheumatoid arthritis

Crosswalk:

M05.40 Rheumatoid myopathy with rheumatoid arthritis of unsp site
M05.411 Rheumatoid myopathy w rheumatoid arthritis of right shoulder
M05.412 Rheumatoid myopathy w rheumatoid arthritis of left shoulder
M05.419 Rheumatoid myopathy w rheumatoid arthritis of unsp shoulder
M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.429 Rheumatoid myopathy with rheumatoid arthritis of unsp elbow
M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.439 Rheumatoid myopathy with rheumatoid arthritis of unsp wrist
M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.449 Rheumatoid myopathy with rheumatoid arthritis of unsp hand
M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.459 Rheumatoid myopathy with rheumatoid arthritis of unsp hip
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.469 Rheumatoid myopathy with rheumatoid arthritis of unsp knee
M05.471 Rheumatoid myopathy w rheumatoid arthritis of right ank/ft
M05.472 Rheumatoid myopathy w rheumatoid arthritis of left ank/ft
M05.479 Rheumatoid myopathy w rheumatoid arthritis of unsp ank/ft
M05.49 Rheumatoid myopathy w rheumatoid arthritis of multiple sites
M05.50 Rheumatoid polyneurop w rheumatoid arthritis of unsp site
M05.511 Rheumatoid polyneurop w rheumatoid arthritis of r shoulder
M05.512 Rheumatoid polyneurop w rheumatoid arthritis of l shoulder
M05.519 Rheu polyneurop w rheumatoid arthritis of unsp shoulder
M05.521 Rheumatoid polyneurop w rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneurop w rheumatoid arthritis of left elbow
M05.529 Rheumatoid polyneurop w rheumatoid arthritis of unsp elbow
M05.531 Rheumatoid polyneurop w rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneurop w rheumatoid arthritis of left wrist
M05.539 Rheumatoid polyneurop w rheumatoid arthritis of unsp wrist
M05.541 Rheumatoid polyneurop w rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneurop w rheumatoid arthritis of left hand
M05.549 Rheumatoid polyneurop w rheumatoid arthritis of unsp hand
M05.551 Rheumatoid polyneurop w rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy w rheumatoid arthritis of left hip
M05.559 Rheumatoid polyneuropathy w rheumatoid arthritis of unsp hip
M05.561 Rheumatoid polyneurop w rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneurop w rheumatoid arthritis of left knee
M05.569 Rheumatoid polyneurop w rheumatoid arthritis of unsp knee
M05.571 Rheumatoid polyneurop w rheumatoid arthritis of right ank/ft
M05.572 Rheumatoid polyneurop w rheumatoid arthritis of left ank/ft
M05.579 Rheumatoid polyneurop w rheumatoid arthritis of unsp ank/ft
M05.59 Rheumatoid polyneuropathy w rheumatoid arthritis mult site
M05.70 Rheu arthritis w rheu factor of unsp site w/o org/sys involv
M05.711 Rheu arthrit w rheu factor of r shoulder w/o org/sys involv
M05.712 Rheu arthrit w rheu factor of l shoulder w/o org/sys involv
M05.719 Rheu arthrit w rheu factor of unsp shldr w/o org/sys involv
M05.721 Rheu arthritis w rheu factor of r elbow w/o org/sys involv
M05.722 Rheu arthritis w rheu factor of l elbow w/o org/sys involv
M05.729 Rheu arthrit w rheu factor of unsp elbow w/o org/sys involv
M05.731 Rheu arthritis w rheu factor of r wrist w/o org/sys involv
M05.732 Rheu arthritis w rheu factor of l wrist w/o org/sys involv
M05.739 Rheu arthrit w rheu factor of unsp wrist w/o org/sys involv
M05.741 Rheu arthritis w rheu factor of r hand w/o org/sys involv
M05.742 Rheu arthritis w rheu factor of left hand w/o org/sys involv
M05.749 Rheu arthritis w rheu factor of unsp hand w/o org/sys involv
M05.751 Rheu arthritis w rheu factor of right hip w/o org/sys involv
M05.752 Rheu arthritis w rheu factor of left hip w/o org/sys involv
M05.759 Rheu arthritis w rheu factor of unsp hip w/o org/sys involv
M05.761 Rheu arthritis w rheu factor of r knee w/o org/sys involv
M05.762 Rheu arthritis w rheu factor of left knee w/o org/sys involv
M05.769 Rheu arthritis w rheu factor of unsp knee w/o org/sys involv
M05.771 Rheu arthrit w rheu fctr of right ank/ft w/o org/sys involv
M05.772 Rheu arthrit w rheu factor of left ank/ft w/o org/sys involv
M05.779 Rheu arthrit w rheu factor of unsp ank/ft w/o org/sys involv
M05.79 Rheu arthritis w rheu factor mult site w/o org/sys involv
M05.80 Oth rheumatoid arthritis with rheumatoid factor of unsp site
M05.811 Oth rheumatoid arthritis w rheumatoid factor of r shoulder
M05.812 Oth rheumatoid arthritis w rheumatoid factor of l shoulder
M05.819 Oth rheu arthritis w rheumatoid factor of unsp shoulder
M05.821 Oth rheumatoid arthritis w rheumatoid factor of right elbow
M05.822 Oth rheumatoid arthritis w rheumatoid factor of left elbow
M05.829 Oth rheumatoid arthritis w rheumatoid factor of unsp elbow
M05.831 Oth rheumatoid arthritis w rheumatoid factor of right wrist
M05.832 Oth rheumatoid arthritis w rheumatoid factor of left wrist
M05.839 Oth rheumatoid arthritis w rheumatoid factor of unsp wrist
M05.841 Oth rheumatoid arthritis w rheumatoid factor of right hand
M05.842 Oth rheumatoid arthritis with rheumatoid factor of left hand
M05.849 Oth rheumatoid arthritis with rheumatoid factor of unsp hand
M05.851 Oth rheumatoid arthritis with rheumatoid factor of right hip
M05.852 Oth rheumatoid arthritis with rheumatoid factor of left hip
M05.859 Oth rheumatoid arthritis with rheumatoid factor of unsp hip
M05.861 Oth rheumatoid arthritis w rheumatoid factor of right knee
M05.862 Oth rheumatoid arthritis with rheumatoid factor of left knee
M05.869 Oth rheumatoid arthritis with rheumatoid factor of unsp knee
M05.871 Oth rheumatoid arthritis w rheumatoid factor of right ank/ft
M05.872 Oth rheumatoid arthritis w rheumatoid factor of left ank/ft
M05.879 Oth rheumatoid arthritis w rheumatoid factor of unsp ank/ft
M05.89 Oth rheumatoid arthritis w rheumatoid factor mult site
M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified
M06.00 Rheumatoid arthritis without rheumatoid factor, unsp site
M06.011 Rheumatoid arthritis w/o rheumatoid factor, right shoulder
M06.012 Rheumatoid arthritis w/o rheumatoid factor, left shoulder
M06.019 Rheumatoid arthritis w/o rheumatoid factor, unsp shoulder
M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
M06.029 Rheumatoid arthritis without rheumatoid factor, unsp elbow
M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist
M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist
M06.039 Rheumatoid arthritis without rheumatoid factor, unsp wrist
M06.041 Rheumatoid arthritis without rheumatoid factor, right hand
M06.042 Rheumatoid arthritis without rheumatoid factor, left hand
M06.049 Rheumatoid arthritis without rheumatoid factor, unsp hand
M06.051 Rheumatoid arthritis without rheumatoid factor, right hip
M06.052 Rheumatoid arthritis without rheumatoid factor, left hip
M06.059 Rheumatoid arthritis without rheumatoid factor, unsp hip
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.069 Rheumatoid arthritis without rheumatoid factor, unsp knee
M06.071 Rheumatoid arthritis w/o rheumatoid factor, right ank/ft
M06.072 Rheumatoid arthritis w/o rheumatoid factor, left ank/ft
M06.079 Rheumatoid arthritis w/o rheumatoid factor, unsp ank/ft
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis w/o rheumatoid factor, multiple sites
M06.20 Rheumatoid bursitis, unspecified site
M06.211 Rheumatoid bursitis, right shoulder
M06.212 Rheumatoid bursitis, left shoulder
M06.219 Rheumatoid bursitis, unspecified shoulder
M06.221 Rheumatoid bursitis, right elbow
M06.222 Rheumatoid bursitis, left elbow
M06.229 Rheumatoid bursitis, unspecified elbow
M06.231 Rheumatoid bursitis, right wrist
M06.232 Rheumatoid bursitis, left wrist
M06.239 Rheumatoid bursitis, unspecified wrist
M06.241 Rheumatoid bursitis, right hand
M06.242 Rheumatoid bursitis, left hand
M06.249 Rheumatoid bursitis, unspecified hand
M06.251 Rheumatoid bursitis, unspecified hand
M06.252 Rheumatoid bursitis, left hip
M06.259 Rheumatoid bursitis, unspecified hip
M06.261 Rheumatoid bursitis, right knee
M06.262 Rheumatoid bursitis, left knee
M06.269 Rheumatoid bursitis, unspecified knee
M06.271 Rheumatoid bursitis, right ankle and foot
M06.272 Rheumatoid bursitis, left ankle and foot
M06.279 Rheumatoid bursitis, unspecified ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.30 Rheumatoid nodule, unspecified site
M06.311 Rheumatoid nodule, right shoulder
M06.312 Rheumatoid nodule, left shoulder
M06.319 Rheumatoid nodule, unspecified shoulder
M06.321 Rheumatoid nodule, right elbow
M06.322 Rheumatoid nodule, left elbow
M06.329 Rheumatoid nodule, unspecified elbow
M06.331 Rheumatoid nodule, right wrist
M06.332 Rheumatoid nodule, left wrist
M06.339 Rheumatoid nodule, unspecified wrist
M06.341 Rheumatoid nodule, right hand
M06.342 Rheumatoid nodule, left hand
M06.349 Rheumatoid nodule, unspecified hand
M06.351 Rheumatoid nodule, right hip
M06.352 Rheumatoid nodule, left hip
M06.359 Rheumatoid nodule, unspecified hip
M06.361 Rheumatoid nodule, right knee
M06.362 Rheumatoid nodule, left knee
M06.369 Rheumatoid nodule, unspecified knee
M06.371 Rheumatoid nodule, right ankle and foot
M06.372 Rheumatoid nodule, left ankle and foot
M06.379 Rheumatoid nodule, unspecified ankle and foot
M06.38 Rheumatoid nodule, vertebrae
M06.39 Rheumatoid nodule, multiple sites
M06.80 Other specified rheumatoid arthritis, unspecified site
M06.811 Other specified rheumatoid arthritis, right shoulder
M06.812 Other specified rheumatoid arthritis, left shoulder
M06.819 Other specified rheumatoid arthritis, unspecified shoulder
M06.821 Other specified rheumatoid arthritis, right elbow
M06.822 Other specified rheumatoid arthritis, left elbow
M06.829 Other specified rheumatoid arthritis, unspecified elbow
M06.831 Other specified rheumatoid arthritis, right wrist
M06.832 Other specified rheumatoid arthritis, left wrist
M06.839 Other specified rheumatoid arthritis, unspecified wrist
M06.841 Other specified rheumatoid arthritis, right hand
M06.842 Other specified rheumatoid arthritis, left hand
M06.849 Other specified rheumatoid arthritis, unspecified hand
M06.851 Other specified rheumatoid arthritis, right hip
M06.852 Other specified rheumatoid arthritis, left hip
M06.859 Other specified rheumatoid arthritis, unspecified hip
M06.861 Other specified rheumatoid arthritis, right knee
M06.862 Other specified rheumatoid arthritis, left knee
M06.869 Other specified rheumatoid arthritis, unspecified knee
M06.871 Other specified rheumatoid arthritis, right ankle and foot
M06.872 Other specified rheumatoid arthritis, left ankle and foot
M06.879 Oth rheumatoid arthritis, unspecified ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites
M06.9 Rheumatoid arthritis, unspecified

UHC - CPT codes not to be reported in CMS 1500 form


Effective for dates of service on or after Sept. 1, 2014, UnitedHealthcare will implement a new policy supported by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). UnitedHealthcare will not reimburse the following codes when reported on a CMS-1500 form or its electronic equivalent by physicians or health care professionals:

G0129
G0175
G0176
G0177
G0302
G0303
G0304
G0305
G0333
G0337
G0378
G0379
G0380
G0381
G0382
G0383
G0384
G0390
G0410
G0411
G0463
G3001
Q0510
Q0511
Q0512
Q0513
Q0514
96376

In addition to the codes adjacent, UnitedHealthcare will also deny codes reported on a CMS-1500 form that are designated “for reporting purposes only” and identified by the designation of Status M or Status Q on the CMS National Physician Fee Schedule (NPFS) Relative Value File. 

Reference: https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=01af50581693b010VgnVCM100000c520720a____

NCD for Single Chamber and Dual Chamber Cardiac Pacemakers


Permanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle. 

The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest, and the pacemaker’s leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small “pocket” in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches. 

On August 13, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD). In this NCD, CMS concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion).

The following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers: 

1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction.  

2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers: 

1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia. 

2. Asymptomatic first degree atrioventricular block. 

3. Asymptomatic sinus bradycardia. 

4. Asymptomatic sino-atrial block or asymptomatic sinus arrest. 

5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia. 

6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart). 

7. Syncope of undetermined cause. 

8. Bradycardia during sleep. 

9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block.

10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy. 

11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia. 

12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged. 

• MACs will pay professional claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, provided the claim contains at least one of the CPT codes of 33206, 33207, or 33208 AND one of the following ICD-9_CM/ICD-10-CM diagnostic codes, and only when the claim is submitted with the KX modifier: 

426.0/I44.2 
426.12/I44.1 
426.13/I44.1 
427.81/I49.5, or 
746.86/Q24.6

• The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and at least one of the diagnosis codes listed above along with the KX modifier: 

426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block 
426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block / I45.19 Other right bundle branch block 
427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia 

• Contractors will return claim lines if the KX modifier is not present using the following message: 

Claim Adjustment Reason Code (CARC) 4: The procedure code is inconsistent with the modifier used or a required modifier is missing.

Remittance Advice Remarks Code (RARC) N517: Resubmit a new claim with the requested information.

• Effective for claims with dates of service on or after August 13, 2013, MACs will pay outpatient institutional claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, (codes C1785, C1786, C2619, or C2620) provided the claim contains the KX modifier, and contains at least one of the CPT codes 33206, 33207, or 33208, AND one of the following ICD-9_CM/ICD-10-CM diagnostic codes : 

426.0/I44.2 
426.12/I44.1 
426.13/I44.1 
427.81/I49.5, or 
746.86/Q24.6 

• MACs will return outpatient institutional claims for implanted permanent cardiac pacemakers that do not meet the preceding requirements.

• The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and diagnosis codes listed above: 

 426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block 
 426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block / I45.19 Other right bundle branch block 
 427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia 

• Effective for claims with dates of service on or after August 13, 2013, MACs will pay inpatient claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, provided the claim contains one of the following ICD-9/ICD-10 diagnosis AND procedure codes: 

37.81/0JH604Z, 0JH634Z, 0JH804Z, 0JH834Z, 
37.82/0JH605Z, 0JH635Z, 0JH805Z, 0JH835Z, or 
37.83/0JH606Z, 0JH636Z, 0JH806Z, 0JH836Z, AND 
426.0/I44.2, 
426.12/I44.1, 
426.13/I44.1, 
427.81/I49.5, or 
746.86/Q24.6 

• The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and diagnosis codes listed above: 

426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block
426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block / I45.19 Other right bundle branch block 
427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia 

In addition, be aware of the following: 

• MACs will deny claims for implanted dual chamber for one of the following CPT codes: 33206, 33207, or 33208 and contains at least one of the following ICD-9-CM/ICD-10-CM diagnosis codes (even if submitted with at least one of the acceptable diagnosis codes listed above): 

426.11/I44.0 
427.31/I48.1/I48.2/I48.91 
427.32/I48.2/I48.3/I48.4/ or I48.91 
427.89/I49.8/ R00.1 
780.2/R55 

MACs will use the following messages when denying claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, containing one of the following HCPCS and/or CPT codes: C1785, C1786, C2619, C2620, 33206, 33207, or 33208, and at least one diagnosis code from the list of ICD-9/ICD-10 diagnosis codes above: 

CARC 96: Non-covered charge(s).

RARC N569: Not covered when performed for the reported diagnosis. 

Group Code - CO (contractual obligation), if claim received with GZ modifier indicating no signed Advance Beneficiary Notice (ABN) is on file or Group Code PR (Patient Responsibility) if occurrence code 32 indicating a signed ABN is on file or occurrence code 32 with modifier GA is present. 

Florida Blue follows Medicare edits for Multiple Diagnostic Procedures


Effective for the date of services from August 1, 2014, Florida Blue will implement a new coding edit that affects payment for multiple diagnostic cardiology procedures performed on the same day by the same provider group. Claims processed for dates of service August 1, 2014 and after will process according to the new rule. 

When multiple diagnostic cardiology procedures are performed in any setting, the primary procedure is allowed at 100 percent. However, allowances for secondary and all subsequent procedures are reduced by 25 percent of the technical component when performed on the same date of service. The primary procedure has the highest total relative value of the diagnostic procedures performed. Additionally, when the primary procedure is billed with multiple units, the first unit will allow at 100 percent and each subsequent unit will be reduced by 25 percent of the technical component. 

Example:

Procedures 78452 and 93306 are submitted for the same date of service: 

• 78452 with 1 unit will allow at 100 percent of the fee schedule amount because it has the highest relative value. 

• 93306 with 1 unit will be reduced by 25 percent of the technical component allowance as it is the lower valued procedure. 

The new coding edit is consistent with CMS payment policies for multiple procedure payment reduction. 

This change affects all Florida Blue products, including BlueCare® (HMO), BlueMedicareSM HMO, BlueChoice® (Preferred Patient Care), BlueMedicareSM PPO, BlueOptionsSM 
(NetworkBlue) and Traditional plans. It also applies to BlueCard® host and Federal Employee Program (FEP) claims. 

For more information and FAQs please visit Coding Edit Change for Multiple Diagnostic Cardiology Procedures

Also see 

Coding Edit Change for Multiple Diagnostic Ophthalmology Procedures


Coding Edit Change for Multiple Therapy Procedures


Coding Edit Change for the Professional Component of Multiple Diagnostic Procedures for Medicare Advantage Plans

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