Efficacy, Diagnoses, Frequency Play Parts in Coverage Limitations

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶