Pneumococcal Vaccine Claims Processing Updates April 2022

The Pneumococcal Vaccine CPT codes will be payable by Medicare. The new codes will be in the 2021 Medicare Physician Fee Schedule Database file update and the annual HCPCS update. 

90677-  Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.

• Which is effective for Dates of Service (DOS) on or after July 1, 2021

90671 - Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

• Which is effective for DOS on or after July 16, 2021 
• The CPT 90677 does not apply for Coinsurance and deductible.
  

A Medicare Administrative Contractor (MAC) will pay institutional providers for these codes based on the Type of Bill (TOB) used. The two payment methods are,

      1. The Medicare Administrative Contractor (MAC) will pay these institutional providers using reasonable cost if you use the following,

• Hospitals (TOBs 12X and 13X)
• Skilled Nursing Facilities (TOBs 22X and 23X)
• Home Health Agencies (TOB 34X)
• Hospital-based Renal Dialysis Facilities (RDFS) (TOB 72X)
• Critical Access Hospitals (CAHs) (TOB 85X)

      2. A MACs will pay these institutional providers based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP) if you use,

• Comprehensive Outpatient Rehabilitation Facilities (TOB 75X)
• Independent RDFs (TOB 72X)
• Indian Health Services (IHS),

• Hospitals (TOBs 12X and 13X)
• Hospices (TOBs 81X and 82X)
• IHS CAHs (TOB 85X)

A MAC will hold  the claims they get before April 1, 2022, for mentioned below CPT codes,

• HCPCS code 90677 with DOS on and after July 1, 2021
• HCPCS code 90671 with DOS on or after July 16, 2021

A MAC will process the claims when Medicare systems are ready on April 4, 2022. Also, your MAC will initiate a mass adjustment for any claims that rejected with HCPCS 90677 with a DOS from July 1, 2021 to September 30, 2021. 

They will also adjust rejected claims with HCPCS code 90671 with dates of service from July 16, 2021 to March 31, 2022. These adjustments will occur after April 4, 2022.

CPT Changes in April 2022 & July 2022

New CPT Codes Included Effective From April 1st, 2022

CPT Description

0306U Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient specific panel for future comparisons to evaluate for MRD

0307U Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient specimens to evaluate for MRD

0308U Cardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, adiponectin, and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for obstructive CAD

0309U Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for major adverse cardiac event

0310U Pediatrics (vasculitis, Kawasaki disease [KD]), analysis of 3 biomarkers (NTproBNP, C-reactive protein, and T-uptake), plasma, algorithm reported as a risk score for KD

0311U Infectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)–based antimicrobial susceptibility for each organisms identified

0312U Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), flow cytometry and indirect immunofluorescence, serum, or plasma and whole blood, individual components reported along with an algorithmic SLE-likelihood assessment

0313U Oncology (pancreas), DNA and mRNA next-generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported as a categorical result (ie, negative, low probability of neoplasia or positive, high probability of neoplasia)

0314U Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant)

0315U Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B)

0316U Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine

0317U Oncology (lung cancer), four-probe FISH (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithmgenerated evaluation reported as decreased or increased risk for lung cancer

0318U Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood

0319U Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection

0320U Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection

0321U Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique

0322U Neurology (autism spectrum disorder [ASD]), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma, results reported as negative or positive for risk of metabolic subtypes associated with ASD

New CPT Codes Included Effective From July 1st, 2022

0714T Transperineal Laser Ablation Of Benign Prostatic Hyperplasia, Including Imaging Guidance

0715T Percutaneous Transluminal Coronary Lithotripsy (List Separately In Addition To Code For Primary Procedure)

0716T Cardiac Acoustic Waveform Recording With Automated Analysis And Generation Of Coronary Artery Disease Risk Score

0717T Autologous Adipose-Derived Regenerative Cell (Adrc) Therapy For Partial Thickness Rotator Cuff Tear; Adipose Tissue Harvesting, Isolation And Preparation Of Harvested Cells, Including Incubation With Cell Dissociation Enzymes, Filtration, Washing And Concentration Of Adrcs

0718T Autologous Adipose-Derived Regenerative Cell (Adrc) Therapy For Partial Thickness Rotator Cuff Tear; Injection Into Supraspinatus Tendon Including Ultrasound Guidance, Unilateral

0719T Posterior Vertebral Joint Replacement, Including Bilateral Facetectomy, Laminectomy, And Radical Discectomy, Including Imaging Guidance, Lumbar Spine, Single Segment

0720T Percutaneous Electrical Nerve Field Stimulation, Cranial Nerves, Without Implantation

0721T Quantitative Computed Tomography (Ct) Tissue Characterization, Including Interpretation And Report, Obtained Without Concurrent Ct Examination Of Any Structure Contained In Previously Acquired Diagnostic Imaging

0722T Quantitative Computed Tomography (Ct) Tissue Characterization, Including Interpretation And Report, Obtained With Concurrent Ct Examination Of Anystructure Contained In The Concurrently Acquired Diagnostic Imaging Dataset (List Separately In Addition To Code For Primary Procedure)

0723T Quantitative Magnetic Resonance Cholangiopancreatography (Qmrcp) Including Data Preparation And Transmission, Interpretation And Report, Obtained Without Diagnostic Magnetic Resonance Imaging (Mri) Examination Of The Same Anatomy (Eg, Organ, Gland, Tissue, Target Structure) During The Same Session

0724T Quantitative Magnetic Resonance Cholangiopancreatography (Qmrcp) Including Data Preparation And Transmission, Interpretation And Report, Obtained With Diagnostic Magnetic Resonance Imaging (Mri) Examination Of The Same Anatomy (Eg, Organ, Gland, Tissue, Target Structure) (List Separately In Addition To Code For Primary Procedure)

0725T Vestibular Device Implantation, Unilateral

0726T Removal Of Implanted Vestibular Device, Unilateral

0727T Removal And Replacement Of Implanted Vestibular Device, Unilateral

0728T Diagnostic Analysis Of Vestibular Implant, Unilateral; With Initial Programming

0729T Diagnostic Analysis Of Vestibular Implant, Unilateral; With Subsequent Programming

0730T Trabeculotomy By Laser, Including Optical Coherence Tomography (Oct) Guidance

0731T Augmentative Ai-Based Facial Phenotype Analysis With Report

0732T Immunotherapy Administration With Electroporation, Intramuscular

0733T Remote Body And Limb Kinematic Measurement-Based Therapy Ordered By A Physician Or Other Qualified Health Care Professional; Supply And Technical Support, Per 30 Days

0734T Remote Body And Limb Kinematic Measurement-Based Therapy Ordered By A Physician Or Other Qualified Health Care Professional; Treatment Management Services By A Physician Or Other Qualified Health Care Professional, Per Calendar Month

0735T Preparation Of Tumor Cavity, With Placement Of A Radiation Therapy Applicator For Intraoperative Radiation Therapy (Iort) Concurrent With Primary Craniotomy (List Separately In Addition To Code For Primary Procedure)

0736T Colonic Lavage, 35 Or More Liters Of Water, Gravity-Fed, With Induced Defecation, Including Insertion Of Rectal Catheter

0737T Xenograft Implantation Into The Articular Surface

90584 Dengue Vaccine, Quadrivalent, Live, 2 Dose Schedule, For Subcutaneous Use

Revised CPT Codes Effective From April 1st, 2022

CPT Description

0022U Targeted genomic sequence analysis panel, cholangiocarcinoma and non-small cell lung neoplasia, DNA and RNA analysis, 1-23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider

Revised CPT Codes Effective From July 1st, 2022

0402T Collagen Cross-Linking Of Cornea, Including Removal Of The Corneal Epithelium, When Performed, And Intraoperative Pachymetry, When Performed

90739 Hepatitis B Vaccine (Hepb), Cpg-Adjuvanted, Adult Dosage, 2 Dose Or 4 Dose Schedule, For Intramuscular Use

Deleted CPT Codes Effective From April 1st, 2022

CPT Description

0097U Gastrointestinal pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 22 targets (Campylobacter [C. jejuni/C. coli/C. upsaliensis], Clostridium difficile [C. difficile] toxin A/B, Plesiomonas shigelloides, Salmonella, Vibrio [V.parahaemolyticus/V. vulnificus/V. cholerae], including specific identification of Vibrio cholerae, Yersinia enterocolitica, Enteroaggregative Escherichia coli [EAEC], Enteropathogenic Escherichia coli [EPEC], Enterotoxigenic Escherichia coli [ETEC] lt/st, Shigalike toxin-producing Escherichia coli [STEC] stx1/stx2 [including specific identification of the E. coli O157 serogroup within STEC], Shigella/Enteroinvasive Escherichia coli [EIEC], Cryptosporidium, Cyclospora cayetanensis, Entamoeba histolytica, Giardia lamblia [also known as G. intestinalis and G. duodenalis], adenovirus F 40/41, astrovirus, norovirus GI/GII, rotavirus A, sapovirus [Genogroups I, II, IV, and V])

0151U Infectious disease (bacterial or viral respiratory tract infection), pathogen specific nucleic acid (DNA or RNA), 33 targets, real-time semi-quantitative PCR, bronchoalveolar lavage, sputum, or endotracheal aspirate, detection of 33 organismal and antibiotic resistance genes with limited semi-quantitative results.

 

Click here for related Updates

COVID-19 vaccine and Monoclonal Antibody Billing for Part B Providers

Guidelines for COVID-19 vaccines and monoclonal antibodies Billing

The patient can get the vaccines including of booster dose and or additional doses.

The patient administered the vaccine with no out of pocket cost for both vaccines and administration of the vaccines.

Vaccinate everyone, including the uninsured, regardless of coverage or network status.

When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don't include the vaccine codes on the claim when the vaccines are free.

If the patient is enrolled in a Medicare Advantage (MA) plan, submit your COVID-19 vaccine and monoclonal antibody infusion claims to Original Medicare in 2020 and 2021. On or after January 1, 2022, claims for vaccine or mAb administrations for Medicare Advantage enrolls should be submitted to the Medicare Advantage plan. 

For services provided to Medicare Advantage enrolls on or after January 1, 2022, contact the Medicare Advantage for guidance on coverage and billing.

Code Description   Vaccine Name Effective date

91300* SARSCOV2 VAC 30MCG/0.3ML IM Pfizer 12/11/2020

0001A ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer 12/11/2020

0002A ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer 12/11/2020

0003A ADM SARSCOV2 30MCG/0.3ML 3RD Pfizer 08/12/2021

0004A ADM SARSCOV2 30MCG/0.3ML BST Pfizer 09/22/2021

91301* SARSCOV2 VAC 100MCG/0.5ML IM Moderna 12/18/2020

0011A ADM SARSCOV2 100MCG/0.5ML1ST Moderna 12/18/2020

0012A ADM SARSCOV2 100MCG/0.5ML2ND Moderna 12/18/2020

0013A ADM SARSCOV2 100MCG/0.5ML3RD Moderna 08/12/2021

91303* SARSCOV2 VAC AD26 .5ML IM Janssen 02/27/2021

0031A ADM SARSCOV2 VAC AD26 .5ML Janssen 02/27/2021

0034A ADM SARSCOV2 VAC AD26 .5ML B Janssen 10/20/2021

91305* SARSCOV2 VAC 30 MCG TRS-SUCR Pfizer 01/03/2022

0051A ADM SARSCV2 30MCG TRS-SUCR 1 Pfizer 01/03/2022

0052A ADM SARSCV2 30MCG TRS-SUCR 2 Pfizer 01/03/2022

0053A ADM SARSCV2 30MCG TRS-SUCR 3 Pfizer 01/03/2022

0054A ADM SARSCV2 30MCG TRS-SUCR B Pfizer 01/03/2022

91306* SARSCOV2 VAC 50MCG/0.25ML IM Moderna 10/20/2021

0064A ADM SARSCOV2 50MCG/0.25MLBST Moderna 10/20/2021

91307* SARSCOV2 VAC 10 MCG TRS-SUCR Pfizer 10/29/2021

0071A ADM SARSCV2 10MCG TRS-SUCR 1 Pfizer 10/29/2021

0072A ADM SARSCV2 10MCG TRS-SUCR 2 Pfizer 10/29/2021

0073A ADM SARSCV2 10MCG TRS-SUCR 3 Pfizer 01/03/2022

M0201** COVID-19 vaccine home admin N/A 06/08/2021

**Providers should not bill for the product if they received it for free.

**The services are covered only in places of service 04, 06, 09, 12, 13, 14, 16, 19, 22, 33, 54, 55, 56, and 60

Monoclonal antibodies and administration

Code Description             Effective date

Q0220* Tixagev and cilgav, 300mg 12/08/2021

Q0221* Tixagev and cilgav, 600mg 02/24/2022

M0220 Tixagev and cilgav inj 12/08/2021

M0221 Tixagev and cilgav inj hm 12/08/2021

Q0222* Bebtelovimab 175 mg 02/11/2022

M0222 Bebtelovimab injection 02/11/2022

M0223 Bebtelovimab injection home 02/11/2022

Q0239* bamlanivimab-xxxx 11/10/2020 – 04/16/2021

M0239 bamlanivimab-xxxx infusion 11/10/2020 – 04/16/2021

Q0240* Casirivi and imdevi 600mg 07/30/2021

M0240 Casiri and imdev repeat 07/30/2021

M0241 Casiri and imdev repeat hm 07/30/2021

Q0243* casirivimab and imdevimab 11/21/2020

M0243 Casirivi and imdevi inj 11/21/2020

Q0244* casirivi and imdevi 1200 mg 06/03/2021

M0244 Casirivi and imdevi inj hm 05/06/2021

Q0245* bamlanivimab and etesevima 02/09/2021

M0245 bamlan and etesev infusion 02/09/2021

M0246 bamlan and etesev infus home 05/06/2021

Q0247** sotrovimab 05/26/2021

M0247 sotrovimab infusion 05/26/2021

M0248 sotrovimab inf, home admin 05/26/2021

Q0249** Tocilizumab for COVID-19 06/24/2021

M0249 Adm Tocilizu COVID-19 1st 06/24/2021

M0250 Adm Tocilizu COVID-19 2nd 06/24/2021

Note:

• *Providers should not bill for the product if they received it for free.
• **The government won’t provide this drug for free.

Click here for COVID-19 CPT Codes

Fee Schedule Updates - 2022

The fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. The CMS develops a fee schedules for following services,

• Physicians Services,
• Ambulance services,
• Clinical laboratory services, 
• Durable Medical Equipment Services,
• Prosthetics Services,
• Orthotics Services,
• Supplies Services.

The Overall, neurosurgery will receive a 3.2% payment cut in 2022. The cut stems from a lower conversion factor from $34.89 in 2021 to $33.58 in 2022. 

In the final rule CMS lowered the conversion factor (CF) from $34.89 in calendar year of 2021 to $33.59 for CY 2022, a decrease of $1.30 (-3.7%). 

This is due in part to the expiration of the 3.75% payment increase provided for in Year of 2021 by the Consolidated Appropriations Act of 2021

With the 2% Medicare sequester set to resume next year and additional Medicare payment cuts of up to 4% possible under pay-as-you-go rules to pay for the American Rescue Plan, providers could be facing up to 9% in payment cuts next year unless Congress intervenes.

Absent congressional actions, a 9.75% cut was scheduled effective January 1, 2022.

*Congress reduced 3% of the scheduled 3.75% cut to the Medicare Physician CF.

Evaluation and management (E/M) visits

The CMS clarifies and refines policies related to split (or shared) evaluation and management (E/M) visits, critical care services, and services furnished by teaching physicians involving residents. 

The Split (or shared) E/M visits are defined as visits provided in a facility setting by a physician and a non-physician provider in the same group. 

The practitioner who provides the substantive portion of the visit would bill for the visit. For 2022, the substantive portion is determined based on the below information,

• Medical History, 
• Physical Exam, 
• Medical Decision Making OR 
• More than half of the total time.

Additionally, critical care services will not be bundled in a global surgical period if unrelated to the surgical procedure. 

The rule clarifies that when a resident participates in providing a service, only the time the teaching physician was present can be included in determining the E/M visit level. Under the primary care exception, only medical decision-making would be used to select the visit level.

Modifier GC to be used when the teaching physician rendered the service to indicate as " The services performed in part by a resident under the direction of a teaching physician.

The CMS permits certain services added to the Medicare telehealth list to remain on the list until December 31, 2023, to collect data to determine whether services should be permanently added to the telehealth list following the COVID-19 public health emergency (PHE).

Payment Modifier Details 

Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. 

• For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier.

Telehealth eye exam

The CMS continues to evaluate the inclusion of telehealth services that were temporarily added during the COVID-19 public health emergency, the agency finalized certain services added to the Medicare telehealth services list through Dec. 31, 2023. 

The AOA raised concerns with the inclusion of the eye exam codes on the telehealth covered services list, yet CMS did not address these codes. However, it did note that all services on the current telehealth covered services list would remain until 2023.

Telehealth Updates - 2022

Telehealth

The telemedicine will be providing to improve a patient's health by permitting two-way, real time interactive audio and video communication between into the patients, and the physician or practitioner at the distant site.

Requirements

• Two way real time interactive audio and video communication must be documented in the medical record.
• Type of communication -Used devices.
• Patient Location and Provider Location.

Place of Services (POS) Changes

• Effective Date - January 1, 2022
• Implementation Date - April 4, 2022

The place of service can be used to specify the setting information necessary to pay the claims correctly. And new place of service introduced place of service (POS 10), revised the description of POS code 02 to meet the overall industry needs.

POS 02 - Telehealth Provided Other than in "Patient’s Home"

Description: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.

POS 10: Telehealth Provided in "Patient’s Home"

Description: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Insurance Updates

Beginning Jan. 1, Anthem and UnitedHealthcare (UHC) will require commercial and Medicare Advantage plans to use new place of service (POS) 10 for telehealth provided in the patient’s home. 

Place of service 02 should continue to be used when telehealth is provided anywhere other than a patient’s home (e.g., a hospital or skilled nursing facility). 

Mental Health Services

Reimbursement for audio-only services for mental health will continue after the public health emergency ends.

Following changes made through new federal legislation, CMS will allow audio-only services to be provided for the diagnosis, evaluation, and treatment of mental health conditions and substance use disorders after the public health emergency (PHE) ends. 

Telehealth Extended Date

UnitedHealthcare will extend the expansion of telehealth access for in-network and out-of-network providers through the national public health emergency period, currently scheduled to end April 15, 2022.

The Centers for Medicare & Medicaid Services (CMS) proposed in the 2022 Physician Fee Schedule to extend telehealth flexibilities through 2023 instead of through the end of the COVID-19 public health emergency, which is expected to run through this year.

APA supported CMS proposal allowing all psychological and neuropsychological testing services to be provided via telehealth after the PHE ends. 

The CMS adopted this proposal, keeping psychological and neuropsychological testing on the temporary (category 3) telehealth list through the end of 2023.

Info: Medicare does not identified a need for new place of service code 10. And the MACs will instruct their providers to continue to use the Medicare billing instructions for Telehealth claims.

Telehealth Codes

Glaucoma Screening

HCPCS/CPT Codes

• G0117 – Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
• G0118 – Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

ICD-10 Codes

B73.02 Onchocerciasis with glaucoma
H26.231 Glaucomatous flecks (subcapsular), right eye
H26.232 Glaucomatous flecks (subcapsular), left eye
H26.233 Glaucomatous flecks (subcapsular), bilateral
H26.239 Glaucomatous flecks (subcapsular), unspecified eye
H40.001 Preglaucoma, unspecified, right eye
H40.002 Preglaucoma, unspecified, left eye
H40.003 Preglaucoma, unspecified, bilateral
H40.009 Preglaucoma, unspecified, unspecified eye
H40.061 Primary angle closure without glaucoma damage, right eye
H40.062 Primary angle closure without glaucoma damage, left eye
H40.063 Primary angle closure without glaucoma damage, bilateral
H40.069 Primary angle closure without glaucoma damage, unspecified eye
H40.10X0 Unspecified open-angle glaucoma, stage unspecified
H40.10X1 Unspecified open-angle glaucoma, mild stage
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.10X3 Unspecified open-angle glaucoma, severe stage
H40.10X4 Unspecified open-angle glaucoma, indeterminate stage
H40.1110 Primary open-angle glaucoma, right eye, stage unspecified
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1113 Primary open-angle glaucoma, right eye, severe stage
H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage
H40.1120 Primary open-angle glaucoma, left eye, stage unspecified
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage
H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage
H40.1133 Primary open-angle glaucoma, bilateral, severe stage
H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1190 Primary open-angle glaucoma, unspecified eye, stage unspecified
H40.1191 Primary open-angle glaucoma, unspecified eye, mild stage
H40.1192 Primary open-angle glaucoma, unspecified eye, moderate stage
H40.1193 Primary open-angle glaucoma, unspecified eye, severe stage
H40.1194 Primary open-angle glaucoma, unspecified eye, indeterminate stage
H40.1210 Low-tension glaucoma, right eye, stage unspecified
H40.1211 Low-tension glaucoma, right eye, mild stage
H40.1212 Low-tension glaucoma, right eye, moderate stage
H40.1213 Low-tension glaucoma, right eye, severe stage
H40.1214 Low-tension glaucoma, right eye, indeterminate stage
H40.1220 Low-tension glaucoma, left eye, stage unspecified
H40.1221 Low-tension glaucoma, left eye, mild stage
H40.1222 Low-tension glaucoma, left eye, moderate stage
H40.1223 Low-tension glaucoma, left eye, severe stage
H40.1224 Low-tension glaucoma, left eye, indeterminate stage
H40.1230 Low-tension glaucoma, bilateral, stage unspecified
H40.1231 Low-tension glaucoma, bilateral, mild stage
H40.1232 Low-tension glaucoma, bilateral, moderate stage
H40.1233 Low-tension glaucoma, bilateral, severe stage
H40.1234 Low-tension glaucoma, bilateral, indeterminate stage
H40.1290 Low-tension glaucoma, unspecified eye, stage unspecified
H40.1291 Low-tension glaucoma, unspecified eye, mild stage
H40.1292 Low-tension glaucoma, unspecified eye, moderate stage
H40.1293 Low-tension glaucoma, unspecified eye, severe stage
H40.1294 Low-tension glaucoma, unspecified eye, indeterminate stage
H40.1310 Pigmentary glaucoma, right eye, stage unspecified
H40.1311 Pigmentary glaucoma, right eye, mild stage
H40.1312 Pigmentary glaucoma, right eye, moderate stage
H40.1313 Pigmentary glaucoma, right eye, severe stage
H40.1314 Pigmentary glaucoma, right eye, indeterminate stage
H40.1320 Pigmentary glaucoma, left eye, stage unspecified
H40.1321 Pigmentary glaucoma, left eye, mild stage
H40.1322 Pigmentary glaucoma, left eye, moderate stage
H40.1323 Pigmentary glaucoma, left eye, severe stage
H40.1324 Pigmentary glaucoma, left eye, indeterminate stage
H40.1330 Pigmentary glaucoma, bilateral, stage unspecified
H40.1331 Pigmentary glaucoma, bilateral, mild stage
H40.1332 Pigmentary glaucoma, bilateral, moderate stage
H40.1333 Pigmentary glaucoma, bilateral, severe stage
H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage
H40.1390 Pigmentary glaucoma, unspecified eye, stage unspecified
H40.1391 Pigmentary glaucoma, unspecified eye, mild stage
H40.1392 Pigmentary glaucoma, unspecified eye, moderate stage
H40.1393 Pigmentary glaucoma, unspecified eye, severe stage
H40.1394 Pigmentary glaucoma, unspecified eye, indeterminate stage
H40.1410 Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified
H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage
H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1420 Capsular glaucoma with pseudoexfoliation of lens, left eye, stage unspecified
H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage
H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1430 Capsular glaucoma with pseudoexfoliation of lens, bilateral, stage unspecified
H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage
H40.1490 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, stage unspecified
H40.1491 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, mild stage
H40.1492 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, moderate stage
H40.1493 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, severe stage
H40.1494 Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, indeterminate stage
H40.151 Residual stage of open-angle glaucoma, right eye
H40.152 Residual stage of open-angle glaucoma, left eye
H40.153 Residual stage of open-angle glaucoma, bilateral
H40.159 Residual stage of open-angle glaucoma, unspecified eye
H40.20X0 Unspecified primary angle-closure glaucoma, stage unspecified
H40.20X1 Unspecified primary angle-closure glaucoma, mild stage
H40.20X2 Unspecified primary angle-closure glaucoma, moderate stage
H40.20X3 Unspecified primary angle-closure glaucoma, severe stage
H40.20X4 Unspecified primary angle-closure glaucoma, indeterminate stage
H40.211 Acute angle-closure glaucoma, right eye
H40.212 Acute angle-closure glaucoma, left eye
H40.213 Acute angle-closure glaucoma, bilateral
H40.219 Acute angle-closure glaucoma, unspecified eye
H40.2210 Chronic angle-closure glaucoma, right eye, stage unspecified
H40.2211 Chronic angle-closure glaucoma, right eye, mild stage
H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage
H40.2213 Chronic angle-closure glaucoma, right eye, severe stage
H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage
H40.2220 Chronic angle-closure glaucoma, left eye, stage unspecified
H40.2221 Chronic angle-closure glaucoma, left eye, mild stage
H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage
H40.2223 Chronic angle-closure glaucoma, left eye, severe stage
H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage
H40.2230 Chronic angle-closure glaucoma, bilateral, stage unspecified
H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage
H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage
H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage
H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage
H40.2290 Chronic angle-closure glaucoma, unspecified eye, stage unspecified
H40.2291 Chronic angle-closure glaucoma, unspecified eye, mild stage
H40.2292 Chronic angle-closure glaucoma, unspecified eye, moderate stage
H40.2293 Chronic angle-closure glaucoma, unspecified eye, severe stage
H40.2294 Chronic angle-closure glaucoma, unspecified eye, indeterminate stage
H40.231 Intermittent angle-closure glaucoma, right eye
H40.232 Intermittent angle-closure glaucoma, left eye
H40.233 Intermittent angle-closure glaucoma, bilateral
H40.239 Intermittent angle-closure glaucoma, unspecified eye
H40.241 Residual stage of angle-closure glaucoma, right eye
H40.242 Residual stage of angle-closure glaucoma, left eye
H40.243 Residual stage of angle-closure glaucoma, bilateral
H40.249 Residual stage of angle-closure glaucoma, unspecified eye
H40.30X0 Glaucoma secondary to eye trauma, unspecified eye, stage unspecified
H40.30X1 Glaucoma secondary to eye trauma, unspecified eye, mild stage
H40.30X2 Glaucoma secondary to eye trauma, unspecified eye, moderate stage
H40.30X3 Glaucoma secondary to eye trauma, unspecified eye, severe stage
H40.30X4 Glaucoma secondary to eye trauma, unspecified eye, indeterminate stage
H40.31X0 Glaucoma secondary to eye trauma, right eye, stage unspecified
H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage
H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage
H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage
H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage
H40.32X0 Glaucoma secondary to eye trauma, left eye, stage unspecified
H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage
H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage
H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage
H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage
H40.33X0 Glaucoma secondary to eye trauma, bilateral, stage unspecified
H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage
H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage
H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage
H40.33X4 Glaucoma secondary to eye trauma, bilateral, indeterminate stage
H40.40X0 Glaucoma secondary to eye inflammation, unspecified eye, stage unspecified
H40.40X1 Glaucoma secondary to eye inflammation, unspecified eye, mild stage
H40.40X2 Glaucoma secondary to eye inflammation, unspecified eye, moderate stage
H40.40X3 Glaucoma secondary to eye inflammation, unspecified eye, severe stage
H40.40X4 Glaucoma secondary to eye inflammation, unspecified eye, indeterminate stage
H40.41X0 Glaucoma secondary to eye inflammation, right eye, stage unspecified
H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage
H40.41X2 Glaucoma secondary to eye inflammation, right eye, moderate stage
H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage
H40.41X4 Glaucoma secondary to eye inflammation, right eye, indeterminate stage
H40.42X0 Glaucoma secondary to eye inflammation, left eye, stage unspecified
H40.42X1 Glaucoma secondary to eye inflammation, left eye, mild stage
H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage
H40.42X3 Glaucoma secondary to eye inflammation, left eye, severe stage
H40.42X4 Glaucoma secondary to eye inflammation, left eye, indeterminate stage
H40.43X0 Glaucoma secondary to eye inflammation, bilateral, stage unspecified
H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage
H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage
H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage
H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage
H40.50X0 Glaucoma secondary to other eye disorders, unspecified eye, stage unspecified
H40.50X1 Glaucoma secondary to other eye disorders, unspecified eye, mild stage
H40.50X2 Glaucoma secondary to other eye disorders, unspecified eye, moderate stage
H40.50X3 Glaucoma secondary to other eye disorders, unspecified eye, severe stage
H40.50X4 Glaucoma secondary to other eye disorders, unspecified eye, indeterminate stage
H40.51X0 Glaucoma secondary to other eye disorders, right eye, stage unspecified
H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage
H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage
H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage
H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage
H40.52X0 Glaucoma secondary to other eye disorders, left eye, stage unspecified
H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage
H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage
H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage
H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage
H40.53X0 Glaucoma secondary to other eye disorders, bilateral, stage unspecified
H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage
H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage
H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage
H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.60X0 Glaucoma secondary to drugs, unspecified eye, stage unspecified
H40.60X1 Glaucoma secondary to drugs, unspecified eye, mild stage
H40.60X2 Glaucoma secondary to drugs, unspecified eye, moderate stage
H40.60X3 Glaucoma secondary to drugs, unspecified eye, severe stage
H40.60X4 Glaucoma secondary to drugs, unspecified eye, indeterminate stage
H40.61X0 Glaucoma secondary to drugs, right eye, stage unspecified
H40.61X1 Glaucoma secondary to drugs, right eye, mild stage
H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage
H40.61X3 Glaucoma secondary to drugs, right eye, severe stage
H40.61X4 Glaucoma secondary to drugs, right eye, indeterminate stage
H40.62X0 Glaucoma secondary to drugs, left eye, stage unspecified
H40.62X1 Glaucoma secondary to drugs, left eye, mild stage
H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage
H40.62X3 Glaucoma secondary to drugs, left eye, severe stage
H40.62X4 Glaucoma secondary to drugs, left eye, indeterminate stage
H40.63X0 Glaucoma secondary to drugs, bilateral, stage unspecified
H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage
H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage
H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage
H40.63X4 Glaucoma secondary to drugs, bilateral, indeterminate stage
H40.811 Glaucoma with increased episcleral venous pressure, right eye
H40.812 Glaucoma with increased episcleral venous pressure, left eye
H40.813 Glaucoma with increased episcleral venous pressure, bilateral
H40.819 Glaucoma with increased episcleral venous pressure, unspecified eye
H40.821 Hypersecretion glaucoma, right eye
H40.822 Hypersecretion glaucoma, left eye
H40.823 Hypersecretion glaucoma, bilateral
H40.829 Hypersecretion glaucoma, unspecified eye
H40.89 Other specified glaucoma
H40.9 Unspecified glaucoma
H42 Glaucoma in diseases classified elsewhere
H44.511 Absolute glaucoma, right eye
H44.512 Absolute glaucoma, left eye
H44.513 Absolute glaucoma, bilateral
H44.519 Absolute glaucoma, unspecified eye
H47.231 Glaucomatous optic atrophy, right eye
H47.232 Glaucomatous optic atrophy, left eye
H47.233 Glaucomatous optic atrophy, bilateral
H47.239 Glaucomatous optic atrophy, unspecified eye
Q15.0 Congenital glaucoma
Z01.020 Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021 Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z71.84 Encounter for health counseling related to travel
Z83.511 Family history of glaucoma
Z98.83 Filtering (vitreous) bleb after glaucoma surgery status

Who Is Covered

Medicare beneficiaries who fall into at least one of the following categories:

• Have diabetes mellitus
• Have a family history of glaucoma
• Are African-Americans aged 50 and older
• Are Hispanic-Americans aged 65 and older

Frequency

• Annually for covered Medicare beneficiaries

Medicare Beneficiary Pays

• Copayment/coinsurance applies
• Deductible applies

Facet Joint Injection

The qualified healthcare providers injects a diagnostic or therapeutic agent into a facet joints to treat the spinal pain or to identify the exact source of pain with using of imaging guidance of either fluoroscopy or CT scan. 

The joints are connecting into two spinal vertebrae together as following, 

• Cervical Level
• Thoracic Level. 

All of the spine, at each level, a pair of small facet joints connects the vertebrae, the bony building blocks of the spine holding the vertebral column together and providing support. 

These small joints may become inflamed due to a variety of conditions including osteoarthritis, disc degeneration, spinal stenosis, or from trauma such as a car accident.

When the facet joints become swollen and enlarged because of injury or arthritis, it causes pain, 

• If the affected joint is in the neck, it may cause headaches and difficulty moving the head. 
• If it is in the back, it may cause pain in the lower back, buttocks, or legs.

In cases where conservative approaches, such as anti-inflammatory medications, chiropractic manipulation, and physical therapy, don’t provide sufficient relief, denervation or injection into or around the facet joint may help relief the pain

For this service, the provider preps and anesthetizes the patient for a facet joint injection. The provider then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis.

• Computed tomography, or CT, is when the provider rotates an X–ray tube and X–ray detectors around a patient, which produces a tomogram, a computer generated cross sectional image; providers use CT to diagnose, manage, and treat diseases.
• Fluoroscopy is a live X–ray where the X–ray image appears on a fluorescent screen television monitor; providers often use fluoroscopy to view body structures while performing procedures.

Do not separately code for multiple injections at the same spinal level and do not bill imaging guidance, specifically fluoroscopy or CT.

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. The facet joint is noted at a specific level by the vertebrae that form it (e.g., C4-5 or L2-3). There are two facet joints at each level, left and right, and there are 28 levels of facet joints.

Each facet joint is supplied by the medial branches of two different spinal nerves. Two to three medial branch nerves innervate each lumbar facet joint, and two nerves innervate each cervical and thoracic facet joint. These nerves are branches of the posterior division of the spinal nerves, located immediately above and below the joint.

For example, innervation of the facet joints at L4-L5 is supplied by medial branches originating from the L3 and L4 spinal nerves. As such, the physician must block two median nerves for each facet joint. In the case of a medial branch nerve block at L4-L5, the physician would inject the medial branches of L3 and L4. For coding purposes, these two injections are considered a single injection service.

CPT Codes

64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

+64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

+64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

+64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

+64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

+64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

+64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Tips

• Codes 64490-64495 are unilateral procedures.
• Use CPT codes 64490 and 64493 to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
• Use CPT add-on codes 64491, 64492 and 64494, 64495 to report second and third additional levels of paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them.
• Report 64490-64495 once per level, irrespective of the number of drugs injected or whether single or multiple punctures are required to anesthetize the target joint at a given level and side.
• Append modifier KX Requirements specified in the medical policy have been met to the line for all diagnostic injections.
• Append the bilateral modifier 50 to the appropriate code when the provider performs bilateral injections/denervations.
• Do not append multiple procedures modifier 51 to +64491, +64492, +64494, or +64495 because these are add-on codes and exempt from multiple procedure concept.
• When your provider performs injections on both sides of one vertebral level, report the base injection code (64490 or 64493) with modifier 50 Bilateral procedure. If the physician injects a second level bilaterally, report the add-on code (+64491 or +64494), also with modifier 50.

OIG Audits - Improper Payments

Recently released audit findings from the Department of Health and Human Services (HHS) Office of Inspector General (OIG) and show that Medicare did not pay physicians for selected facet-joint denervation sessions in accordance with Medicare requirements. Due to inadequate oversight, the Centers for Medicare & Medicaid Services (CMS) improperly paid physicians a total of $9.5 million for certain facet-joint denervation sessions. Based on OIG recommendations, CMS plans as following

• Direct the Medicare Administrative Contractors (MACs) to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions.
• Instruct the MACs to notify the physicians who received potential overpayments so they can exercise reasonable diligence to identify, report, and return any overpayments per the 60-day rule,
• Assess the effectiveness of oversight mechanisms specific to detecting or preventing improper payments to physicians for facet-joint denervation sessions and modify the oversight mechanisms based on that assessment; and,
• Direct the MACs to review claims for denervation sessions after the OIG audit period (dates of service from January 2019 through August 2020) to recover any improper payments.

This highlights the importance of verifying with your MAC the limitations of coverage's to avoid inappropriate billing for and overuse of spinal facet-joint denervation for pain management.