Part B Insider (Multispecialty) Coding Alert

Published on Tue Oct 14, 2003 PDF

The Part B carriers are constantly hard at work defining what Medicare will cover in their states. Even though policies may differ from state to state, it's still worth seeing what rules are coming into place elsewhere, because you could be next.
 
Carrier Cahaba GBA introduced a draft LMRP in Georgia for the cancer drug Bexxar, for which the carrier now accepts unlisted-drug code J9999. Cahaba will cover Bexxar for ICD-9 Codes 200.00-200.88 (Lymphosarcoma and reticulosarcoma) and 202.00-202.98 (Other malignant neoplasms of lymphoid and histiocytic tissue). Patients must have non-Hodgkins lymphoma that is "refractory to Rituximab" and has relapsed following chemotherapy.
 
Another draft Cahaba policy says the carrier will cover Velcade (also using J9999) only with ICD-9 code 203.00 (Multiple myeloma, without mention of remission).
 
Noridian Administrative Services unveiled a number of draft LMRPs for all its states, including one covering MRI and CT scans of the chest/thorax. Noridian won't pay for CT to measure calcification of the coronary arteries, sometimes referred to as "ultrafast CT," because this is a screening benefit. You should bill for these claims only under the unlisted-procedure code 76499 (Unlisted diagnostic radiographic procedure). 
 
Noridian offers a long list of ICD-9 codes it will cover for both MRIs and CTs of the chest/thorax, but strikes out several codes. It won't cover the tests for ICD-9 225.1 (Benign neoplasm of cranial nerves), 239.7-239.9 (Neoplasms of unspecified nature), 353.0 (Brachial plexus lesions), 459.2 (Compression of vein) or 786.00-786.09 (Dyspnea and respiratory abnormalities).
 
In another policy, Noridian says it will cover cardiac MRI only for patients with aortic disease, ischemic heart disease and post-myocardial infarction, cardiomyopathy, right ventricular lesion, pericardial disease, valvular heart disease, cardiac masses, or congenital heart disease.
 
You have until Dec. 15 to comment on all of the above draft policies.
 
Meanwhile, Cigna Healthcare released a draft policy for off-label uses of chemotherapy drugs. Cigna will cover them if their use is supported and not contraindicated in one of three drug handbooks, a national coverage determination or LMRP has established their reasonableness, the provider is treating a carcinoma of unknown primary site "as if" the primary site were known, or the provider is treating a tumor with uncharacteristic histology for its location. You have until Nov. 16 or later to comment, depending on your state.