Medicare national coverage determination manual chapter 1

Code E combines the function of a ventilator with those of any combination or all of the following:. Claims for any of the HCPCS codes listed above that are submitted on the same claim or that overlap any date s of service for E is considered to be unbundling. Claims for code E with a date s of service that overlaps date s of service for any of the following scenarios are considered as a claim for same or similar equipment when the beneficiary:.

Claims for code E with a date s of service that overlaps date s of service in a rental month for any of the items listed above are considered as a claim for same or similar equipment. Suppliers are encouraged to be sure that the correct category of product is provided and billed to avoid errors in HCPCS coding.

Each of these disease categories are conditions where the specific presentation of the disease can vary from patient to patient. For conditions such as these, the specific treatment plan for any individual patient will vary as well. Choice of an appropriate treatment plan, including the determination to use a ventilator vs. In the event of a claim review, there must be sufficiently detailed information in the medical record to support the treatment selected.

An upgrade is defined as an item that goes beyond what is medically necessary under Medicare's coverage requirements. In some cases, CMS policy that allows for billing of upgrade modifiers can be used when providing an item or service that is considered beyond what is medically necessary. This is NOT applicable to ventilators in the situations described above.

Upgrade billing across different payment categories is not possible. Claims for items billed for upgrade across different payment categories will be rejected as unprocessable. Ventilators are classified in the FSS payment category. The monthly rental payment for items in this pricing category is all-inclusive meaning there is no separate payment by Medicare for any options, accessories or supplies used with a ventilator.

In addition, all necessary maintenance, servicing, repairs and replacement are also included in the monthly rental. Medicare does not cover spare or back-up equipment. Backup equipment must be distinguished from multiple medically necessary items which are defined as identical or similar devices, each of which meets a different medical need for the beneficiary.

Although Medicare does not pay separately for backup equipment, Medicare will make a separate payment for a second piece of equipment if it is required to serve a different medical purpose that is determined by the beneficiary's medical needs. The following are examples of situations in which a beneficiary would qualify for both a primary ventilator and a secondary ventilator:.

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RT-right, LT-left, bilateral. Medical history and physical examination completed and documented prior to surgery? Does documentation support the required diagnoses are present primary and secondary codes, if applicable? The patient has impairment of visual function due to cataract s and all of the following criteria are met and clearly documented:.

Does the documentation support the extraordinary work performed during interoperative or postoperative periods in a subset of cataract operations including:. Is the documentation showing the procedure done less than 90 days after the cataract surgery?

Does the documentation show medical necessity if the capsulotomy is performed more than once on the same time, or a separate episode of care, the rationale and indication are clear? There must be clear documentation in the medica record showing significant visual debility, preoperative uveitis, chronic glaucoma, diabetic mellitus or prolonged use of pilocarpine hydrochloride. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories.

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Please click here to see all U. Government Rights Provisions. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT The ADA does not directly or indirectly practice medicine or dispense dental services.

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This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement. The scope of this license is determined by the ADA, the copyright holder. End users do not act for or on behalf of the CMS. Serving KY and OH. IVR: Cataract Services Decision Tree This set of questions will assist with review of documentation requirements: 1.

Which Cataract Service Code is being administered and billed? Is the provider specialty 18 Opthamology or KY 41 Optometrist? Is a comprehensive opthalomologic exam present?

Is an operative report present? Is there an opthalmic biometry? Does the documentation support the procedure billed as medically neessary? Physician documentation specifying rationale.