Coding Guidance for Certain CPT Codes - All Claims

20.4 - Coding Guidance for Certain CPT Codes - All Claims (Rev. 3475, Issued: 03-04-16, Effective: 06-06-16, Implementation: 06-06-16) The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128. • CPT Codes 96105, 97545, and 97546. Providers report code 96105, assessment of aphasia with interpretation and report in 1- hour units. This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented. If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented. It is common practice for regular assessment of a patient’s progress in therapy to be documented in the chart, and this may be done using test items taken from the formal examinations. This is considered to be part of the treatment and should not be billed as 96105 unless a full, formal assessment is completed. Other timed physical medicine codes are 97545 and 97546. The interval for code 97545 is 2 hours and for code 97546, 1 hour. These are specialized codes to be used in the context of rehabilitating a worker to return to a job. The expectation is that the entire time period specified in the codes 97545 or 97546 would be the treatment period, since a shorter period of treatment could be coded with another code such as codes 97110, 97112, or 97537. (Codes 97545 and 97546 were developed for reporting services to persons in the worker’s compensation program, thus CMS does not expect to see them reported for Medicare patients except under very unusual circumstances. Further, CMS would not expect to see code 97546 without also seeing code 97545 on the same claim. Code 97546, when used, is used in conjunction with 97545.) • CPT Code 97026 Effective for services performed on or after October 24, 2006, the Centers for Medicare & Medicaid Services announce a NCD stating the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is non-covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries. Further coverage guidelines can be found in the National Coverage Determination Manual (Pub. 100-03), section 270.6. Contractors shall deny claims with CPT 97026 (infrared therapy incident to or as a PT/OT benefit) and HCPCS E0221 or A4639, if the claim contains any of the following diagnosis codes: ICD-9-CM 250.60 - 250.63 354.4, 354.5, 354.9 355.1 - 355.4 355.6 - 355.9 356.0, 356.2-356.4, 356.8-356.9 357.0 - 357.7 674.10, 674.12, 674.14, 674.20, 674.22, 674.24 707.00 -707.07, 707.09-707.15, 707.19 870.0 - 879.9 880.00 - 887.7 890.0 - 897.7 998.31 - 998.32 ICD-10-CM See Addendum A Chapter 5, Section 20.4 (at end of this chapter) for the list of ICD 10- CM diagnosis codes that require denial with the above HCPCD codes. The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three. Group Code: CO CARC: 50 RARC: N/A MSN: 21.11 Advanced Beneficiary Notice (ABN): Physicians, physical therapists, occupational therapists, outpatient rehabilitation facilities (ORFs), comprehensive outpatient rehabilitation facilities (CORFs), home health agencies (HHA), and hospital outpatient departments are liable if the service is performed, unless the beneficiary signs an ABN. Similarly, DME suppliers and HHA are liable for the devices when they are supplied, unless the beneficiary signs an ABN.