CR12377 Updates Coding in Medicare Claims Processing Manual

Code updates prompted the release of Change Request (CR) 12377 by the Centers for Medicare & Medicaid Services (CMS) on Oct. 13. The updates to chapters 3, 18, and 32 of the Medicare Claims Processing Manual Pub. 100-04 are effective Nov. 17, 2021. CR12377 further clarifies that “Unless otherwise specified, the effective date is the date of service.”

With the implementation date nearing, now is the time to make sure you and your fellow coders and billers are aware of these changes. Let’s take a closer look, so you know what to expect.

Chapter 3 – Inpatient Hospital Billing

90.3 – Stem Cell Transplantation

Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. In this section, ICD-10-PCS codes are added to clearly and more precisely identify allogeneic and autologous stem cell transplantation procedures. CR12377 adds the following ICD-10-PCS codes:

Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) – 30230G2,30230G3, 30230Y2, 30230Y3, 30233G2, 30233G3, 30233Y2, 30233Y3, 30240G2, 30240G3, 30240Y2, 30240Y3, 30243G2, 30243G3, 30243Y2, and 30243Y3.

Autologous Stem Cell Transplantation (AuSCT) – 30230C0, 30230G0, 30230Y0, 30233G0, 30233C0, 30233Y0, 30240C0, 30240G0, 30240Y0, 30243C0, 30243G0, and 30243Y0.

90.3.2 – Autologous Stem Cell Transplantation (AuSCT)

Autologous stem cell transplantation (AuSCT) is a technique for restoring stem cells using the patient’s own previously-stored cells. The update adds the following list of ICD-10-PCS codes, instructing, “If ICD-10-PCS is applicable, use the following Procedure Codes and Descriptions.”

Also updated is the list of ICD-10-CM codes and code ranges for reporting conditions for which AuSCT is covered. The final modification in this section is the addition of a list of non-covered conditions and their corresponding ICD-10-CM codes.

90.4.2 – Billing for Liver Transplant and Acquisition Services

The Medicare Code Editor (MCE) is CMS’ inpatient code editor. It is used to detect and report claim errors based on coding listed on UB-04 claims submitted to Medicare. In this section, before the list of nationally covered diagnosis codes, the following statement is added, “The MCE contains a limited coverage edit for liver transplant procedures using below ICD-10-CM codes if ICD-10-CM is applicable.” Following the list of covered codes, are lists added to specify local discretion covered diagnosis codes and nationally non-covered diagnosis codes.

The final update in this section involves two ICD-10-PCS codes. The changes are in bold.

The MCE contains a limited coverage edit for liver transplant procedures using ICD-10-PCS codes, if ICD-10-PCS code is applicable.

0FY00Z0 – Transplantation of Liver, Allogeneic, Open Approach

0FY00Z1-Transplantation of Liver, Syngeneic, Open Approach

Chapter 18 – Preventive and Screening Services

230.3 – Diagnosis Code Reporting Requirements

CR 12377 modifies the verbiage in this section and adds a list of qualifying high-risk diagnosis codes. According to the change, CMS will allow coverage for HBV screening (HCPCS Level II G04990) for subsequent visits only when services are reported with Z11.59 Encounter for screening for other viral diseases AND one of the high-risk diagnosis codes from the new list.

Also updated is the list of Z codes that can be reported with Z11.59 for coverage of HBV screening (CPT® codes 86704, 86706, 87340, and 87341) in pregnant women. You’ll find similar verbiage modifications and code updates in the last part of this section. Changes are in bold.

For claims with dates of service on or after September 28, 2016, CMS will allow coverage for HBV screening (CPT codes 86704, 86706, 87340 and 87341) in pregnant women only when services are reported with the following diagnosis codes:

Z11.59 – Encounter for screening for other viral diseases, and,

Z72.89 – Other problems related to lifestyle, and, also one of the following diagnosis codes below:

O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester

O09.91 Supervision of high risk pregnancy, unspecified, first trimester

O09.92 Supervision of high risk pregnancy, unspecified, second trimester

O09.93 Supervision of high risk pregnancy, unspecified, third trimester

230.4 – Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages

The updates in this section are minor. A few terms are added throughout for clarification and a phrase is added (in bold) regarding denying services for HBV screening.

Denying services for HBV screening, HCPCS G0499, for subsequent visits, when ICD-10 diagnosis code, and one of the appropriate high-risk ICD-10 diagnosis codes noted in section 230.3 are not present on the claim.

Chapter 32 – Billing Requirements for Special Services

90 – Stem Cell Transplantation

The first addition in this chapter is a list of ICD-10-PCS procedure codes for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT).

Also updated is the list of diagnosis codes for reporting the underlying condition necessitating treatment. Covered conditions include various types of leukemia, aplastic anemia, severe combined immunodeficiency disease (SCID), Wiskott-Aldrich syndrome, myelodysplastic syndrome, multiple myeloma, myelofibrosis (MF), and sickle cell disease.

Similarly, CR12377 adds a list of ICD-10-PCS procedure codes for Autologous Stem Cell Transplantation (AuSCT). It also updates the list of ICD-10-CM codes that cover AuSCT. Specific diagnosis codes for nationally non-covered indications for HSCT and AuSCT are added, as well.

90.2 – HCPCS and Diagnosis Coding – ICD-10-CM Applicable

In this section, the primary changes are the addition of phrases the indicate the appropriate ICD-10-CM codes that providers need to use for coverage of allogeneic stem cell transplantation

90.2.1 HCPCS and Diagnosis Coding for Stem Cell Transplantation ICD-10-CM Applicable

Here, CR12377 expands the list of ICD-10 diagnosis codes for covered conditions that can be reported with AuSCT services considerably.

90.3 – Non-Covered Conditions

Additions are in bold.

Autologous stem cell transplantation is not covered for the following conditions:

a) Acute leukemia not in remission prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C91.00, C92.00, C93.00, C94.00, and C95.00)

b) Chronic granulocytic leukemia prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM code C92.10);

c) Solid tumors prior to October 1, 2000 (other than neuroblastoma) (if ICD10-CM is applicable, ICD-10-CM codes C00.0 – C80.2 and D00.0 – D09.9);

d) Multiple myeloma prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C90.00, C90.01, C90.02 and D47.Z9);

e) Tandem transplantation, on or after October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C90.00, C90.01, C90.02, and D47.Z9);

f) Non- primary amyloidosis on or after 10/01/00, for all Medicare beneficiaries

g) Primary AL amyloidosis effective October 1, 2000, through March 14, 2005 for Medicare beneficiaries age 64. (if ICD-10-C M is applicable, ICD-10-CM codes E85.4, E85.81, E85.9, and E85.89);

90.4 – Edits

Changes are in bold.

As the ICD-10-CM codes E85.4, E85.81, E85.89, and E85.9 amyloidosis does not differentiate between primary and non-primary, A/B MACs (B) should perform prepay reviews on all claims with a diagnosis of ICD-10-CM codes E85.4, E85.81, E85.89, and E85.9 and a HCPCS procedure code of 38241 to determine whether payment is appropriate.

90.5 – Suggested MSN and RA Messages

The only modification in the section is the addition of “CARC” before “- 150, Payment adjusted because the payer deems the information submitted does not support this level of service.”

90.6 – Clinical Trials for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)

Medicare contractors will pay for claims for HSCT for MDS when the service was provided pursuant to a Medicare-approved clinical study under CED; these services are paid only in the inpatient setting (Type of Bill (TOB) 11X), as outpatient Part B (TOB 13X), and in Method II critical access hospitals (TOB 85X). For payment, certain codes must be reported.

Key changes here are the addition of those specific codes: ICD-10-PCS procedure codes 30230C0, 30230G0, 30230Y0, 30233G0, 30233C0, 30233Y0, 30240C0, 30240G0, 30240Y0, 30243C0, 30243G0, 30243Y0 and ICD-10-CM diagnosis codes D46.A, D46.B, D46.C, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4.

130.1 – Billing and Payment Requirements

New to this is the statement, “Note: Please note that effective December 31, 2020 evaluation and management service code 99201 is end-dated.”

200.2- ICD-10 Diagnosis Codes for Vagus Nerve Stimulation

CR12377 adds two diagnosis codes to the list of codes used when billing for vagus nerve stimulation.

• G40.833 Dravet syndrome, intractable, with status epilepticus
• G40.834 Dravet syndrome, intractable, without status epilepticus

200.5 – Medicare Summary Notice (MSN), Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Messages

The only update in this section is the addition of “Alert:” after M38.

What Instigated CR12377 Updates?

This Change Request (CR) constitutes an update to Pub. 100-04, Chapter 3, Sections 90.3, 90.3.2, and 90.4.2; Chapter 18, Sections 230.3, and 230.4; Chapter 32, Sections 90, 90.2, 90.2.1, 90.3, 90.4, 90.5, 90.6, 130.1, 200.2, and 200.5 for the Billing Requirements of the Medicare Claims Processing manual due to NCDs 110.23, 160.18, 210.6, and 260.1 in April 2021 CR 12027, and 20.20, in July 2021 CR 12124 update in International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs).

CMS

For more information on the updates to the Medicare Claims Processing Manual, see Change Request 12377.

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Stacy Chaplain

Stacy Chaplain, MD, CPC, is a development editor at AAPC. She has worked in medicine for more than 20 years, with an emphasis on education, writing, and editing since 2015. Chaplain received her Bachelor of Arts in biology from the University of Texas at Austin and her doctorate in medicine from the University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Ore., local chapter.

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