Procedure Codes, Revenue Codes, and Modifiers

The (837) Professional and Institutional electronic claims and the paper claims have been modified to accept up to four Procedure Code Modifiers

Revenue Code  -  Procedure Code - Description

821 - 90935 Hemodialysis procedure with single physician evaluation. Limited to 156 units per year.

821 - 90937 Hemodialysis procedure requiring repeated evaluations with or without substantial revision of dialysis prescription. Limited to 156 units per year.

831 -841 - 851 - 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) with single physician evaluation.

831 841 851 -  90947 Dialysis procedure other than hemodialysis (e. g. peritoneal, hemofiltration) requiring repeated evaluations with or without substantial revision of dialysis prescription.

831 851 841-  90993 Dialysis training, patient, including helper. Limited to 12 units per lifetime.250- Q4081 Injection, epogen 250-  J0882 Injection, darbepoetin alfa

Hemodialysis

The following table lists Hemodialysis tests and frequency of coverage:

Frequency                  Covered Tests
Per treatment    All hematocrit and clotting time tests furnished incidentally to dialysis treatments.
Weekly             Prothrombin time for patients on anticoagulant therapy; serum creatinine, BUN.
Monthly            Alkaline Phosphates LDH Serum Biocarbonate Serum Calcium
                        Serum Chloride
                        Serum Phosphorous
                        Serum Potassium
                        SGOT
                        Total Protein

All laboratory testing sites providing services to Medicaid recipients, either directly by provider or through contract, must be certified by Clinical Laboratory Improvement Amendments (CLIA) that they provide the required level of complexity for testing. Providers are responsible for assuring

Medicaid that they strictly adhere to all CLIA regulations and for providing Medicaid waiver certification numbers as applicable. Laboratories that do not meet CLIA certification standards are not eligible for reimbursement for laboratory services from Medicaid.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11X, 12X, 13X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

procedure/HCPCS Codes 33240©

Insert pulse generator 33241©

Remove pulse generator 33243©

Remove eltrd/thoracotomy 33244©

Remove eltrd, transven 33249©

Eltrd/insert pace-defib

Effective for services furnished on or after January 1, 2012, the American Medical Association (AMA) changed the descriptor for procedure  code 33249 to read “Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.”

This has necessitated the removal of HCPCS code C1882 (Cardioverter-defibrillator, other than single or dual chamber (implantable)) from the list of those device codes required to be billed with procedure code 33249 on the procedure-to-device edit list, since this link is no longer clinically appropriate. CMS is making this change retroactive to January 1, 2012.

Q: Is prior authorization required?

A: Yes, procedure  codes 33230, 33231, 33240, 33249, 33262, 33263 and 33264 are included in the Cardiology Prior Authorization Program