Capsule Endoscopy (L30141)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30141 LCD Title Capsule Endoscopy Contractor's Determination Number GI-009 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 12/16/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 03/01/2012 Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862(a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.
Indications and Limitations of Coverage and/or Medical Necessity
Capsule endoscopy is a noninvasive diagnostic imaging device for use in viewing the gastrointestinal tract, especially the small bowel, which is not accessible to standard upper endoscopy and colonoscopy. A small capsule (approximately 11x30mm) is swallowed and moves through the GI tract propelled by peristalsis, transmitting video pictures. The video images are transmitted to sensors taped to the body and stored on a portable recorder. The strength of the signal is used to calculate the position of the capsule as it passes through the GI tract. Video images are stored on a portable recorder and later downloaded to a computer, from which they may be viewed and documented. The capsule passes naturally from the body with the stool, and since it is disposable, is not recovered.
Indications:
I. Occult gastrointestinal bleeding
This test is indicated for the diagnosis of occult gastrointestinal bleeding in the anemic patient when:
1. The site of bleeding has not previously been identified by upper gastrointestinal endoscopy, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
2. The diagnosis of angiodysplasias of the GI tract is suspected, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
3. Patients have documented continuing GI blood loss and anemia secondary to bleeding, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
II. Other indications:
1. When the diagnosis of Crohn's disease is suspected but not diagnosed.
2. When the diagnosis of Crohn's disease is known but it is necessary to determine whether there is involvement of the small bowel as well.
3. When a diagnosis of colitis of an indeterminate type, affecting the colon, is known and a more specific diagnosis is sought by evaluating possible small bowel involvement.
4. As a primary procedure in the evaluation of suspected, but undiagnosed, small bowel neoplasm, regional enteritis, or malabsorption syndrome.
III. Capsule Endoscopy is payable when all of the following criteria are met:
1. Patients are receiving services using FDA approved devices.
2. The service is performed by physicians trained in endoscopy or in an independent diagnostic testing facility under the general supervision of a physician trained in endoscopy procedures.
Limitations
IV. Capsule Endoscopy is not considered medically necessary, and is not covered, for:
1. The confirmation of lesion pathology, or the management of conditions diagnosed by prior endoscopy (including push enteroscopy), colonoscopy or radiological procedures.
2. Patients with hematemesis.
3. The management, as opposed to the diagnosis, of Crohn's Disease, other inflammatory conditions, neoplasms and malabsorbtion syndromes of the small intestine.
V. Capsule endoscopy of the esophagus has been used by some practitioners for patients with suspected gastroesophageal reflux disease, Barrett's Esophagus, or esophageal varices. However, mere visualization will not diagnose Barrett's Esophagus (i.e., a biopsy is needed), and there is no need, nor is it standard, to monitor treatment of GERD, varices, etc. by this method (i.e., patients with symptoms will need upper endoscopy to determine severity of disease and potential complications). Since the findings will not alter the treatment plan, these will be denied as not medically necessary.
VI. Patency Capsule testing is not covered. It is used to verify adequate patency of the gastrointestinal tract prior to administration of the PillCam video capsule in patients with known or suspected strictures. There are insufficient studies available to support coverage.
The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure testing" under contraindications for the small bowel capsule.
Indications:
I. Occult gastrointestinal bleeding
This test is indicated for the diagnosis of occult gastrointestinal bleeding in the anemic patient when:
1. The site of bleeding has not previously been identified by upper gastrointestinal endoscopy, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
2. The diagnosis of angiodysplasias of the GI tract is suspected, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
3. Patients have documented continuing GI blood loss and anemia secondary to bleeding, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.
II. Other indications:
1. When the diagnosis of Crohn's disease is suspected but not diagnosed.
2. When the diagnosis of Crohn's disease is known but it is necessary to determine whether there is involvement of the small bowel as well.
3. When a diagnosis of colitis of an indeterminate type, affecting the colon, is known and a more specific diagnosis is sought by evaluating possible small bowel involvement.
4. As a primary procedure in the evaluation of suspected, but undiagnosed, small bowel neoplasm, regional enteritis, or malabsorption syndrome.
III. Capsule Endoscopy is payable when all of the following criteria are met:
1. Patients are receiving services using FDA approved devices.
2. The service is performed by physicians trained in endoscopy or in an independent diagnostic testing facility under the general supervision of a physician trained in endoscopy procedures.
Limitations
IV. Capsule Endoscopy is not considered medically necessary, and is not covered, for:
1. The confirmation of lesion pathology, or the management of conditions diagnosed by prior endoscopy (including push enteroscopy), colonoscopy or radiological procedures.
2. Patients with hematemesis.
3. The management, as opposed to the diagnosis, of Crohn's Disease, other inflammatory conditions, neoplasms and malabsorbtion syndromes of the small intestine.
V. Capsule endoscopy of the esophagus has been used by some practitioners for patients with suspected gastroesophageal reflux disease, Barrett's Esophagus, or esophageal varices. However, mere visualization will not diagnose Barrett's Esophagus (i.e., a biopsy is needed), and there is no need, nor is it standard, to monitor treatment of GERD, varices, etc. by this method (i.e., patients with symptoms will need upper endoscopy to determine severity of disease and potential complications). Since the findings will not alter the treatment plan, these will be denied as not medically necessary.
VI. Patency Capsule testing is not covered. It is used to verify adequate patency of the gastrointestinal tract prior to administration of the PillCam video capsule in patients with known or suspected strictures. There are insufficient studies available to support coverage.
The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure testing" under contraindications for the small bowel capsule.
Coding Information
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.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 071x | Clinic - Rural Health |
| 072x | Clinic - Hospital Based or Independent Renal Dialysis Center |
| 073x | Clinic - Freestanding |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
CPT/HCPCS 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.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
| 0409 | Other Imaging Services - Other Imaging Services |
| 0519 | Clinic - Other Clinic |
| 520X | Free-Standing Clinic - General Classification |
| 0750 | Gastro-Intestinal (GI) Services - General Classification |
| 0929 | Other Diagnostic Services - Other Diagnostic Service |
| 0960 | Professional Fees - General Classification |
| 0972 | Professional Fees - Radiology - Diagnostic |
| 0973 | Professional Fees - Radiology - Therapeutic |
| 0975 | Professional Fees - Operating Room |
| 0982 | Professional Fees - Outpatient Services |
| 0983 | Professional Fees - Clinic |
| 0987 | Professional Fees - Hospital Visit |
| 0988 | Professional Fees - Consultation |
For Patency Capsule Testing
CPT 91299 should be reported
| 91110 | GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT |
| 91111 | GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT |
| 91299 | UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE |
ICD-9 Codes that Support Medical Necessity
*ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
Note: ICD-9 codes must be coded to the highest level of specificity.
| 152.0 - 152.9 | MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE |
| 235.2 | NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM |
| 280.0 | IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) |
| 280.9 | IRON DEFICIENCY ANEMIA UNSPECIFIED |
| 537.82 | ANGIODYSPLASIA OF STOMACH AND DUODENUM (WITHOUT HEMORRHAGE) |
| 537.83 | ANGIODYSPLASIA OF STOMACH AND DUODENUM WITH HEMORRHAGE |
| 555.0 | REGIONAL ENTERITIS OF SMALL INTESTINE |
| 555.1 | REGIONAL ENTERITIS OF LARGE INTESTINE |
| 555.2 | REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE |
| 555.9 | REGIONAL ENTERITIS OF UNSPECIFIED SITE |
| 558.9 | OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS |
| 562.02 | DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE |
| 562.03 | DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE |
| 569.82 | ULCERATION OF INTESTINE |
| 569.84 | ANGIODYSPLASIA OF INTESTINE (WITHOUT HEMORRHAGE) |
| 569.85 | ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE |
| 578.1 | BLOOD IN STOOL |
| 578.9 | HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED |
| 579.0 | CELIAC DISEASE |
| 579.1 | TROPICAL SPRUE |
| 579.9 | UNSPECIFIED INTESTINAL MALABSORPTION |
| 787.91 | DIARRHEA |
| 792.1 | NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS |
| 793.4 | NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
All ICD-9 codes not listed above as covered.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
Documentation supporting the medical necessity must be made available to Medicare upon request.
1. It is not sufficient merely to link the procedure to a payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be supported and documented with the medical record for the procedure to be paid.
2. Photographic copies of the video images, with the beneficiary's name and the date of service included in the picture must be available for review.
3. The medical records must document the need for this test, and contain reports of previous endoscopies, and/or diagnostic radiological procedures performed prior to this capsule endoscopy but during the same current episode of illness.
4. The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss in beneficiaries who had the capsule imaging performed for gastrointestinal bleeding.
5. The medical record must document that a beneficiary who had the capsule imaging performed for Crohn's disease, had a suspected diagnosis of the disease that needed to be confirmed, or if the diagnosis was known, it was necessary to determine involvement of the small bowel.
1. It is not sufficient merely to link the procedure to a payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be supported and documented with the medical record for the procedure to be paid.
2. Photographic copies of the video images, with the beneficiary's name and the date of service included in the picture must be available for review.
3. The medical records must document the need for this test, and contain reports of previous endoscopies, and/or diagnostic radiological procedures performed prior to this capsule endoscopy but during the same current episode of illness.
4. The medical record must document the presence of gastrointestinal bleeding and anemia secondary to blood loss in beneficiaries who had the capsule imaging performed for gastrointestinal bleeding.
5. The medical record must document that a beneficiary who had the capsule imaging performed for Crohn's disease, had a suspected diagnosis of the disease that needed to be confirmed, or if the diagnosis was known, it was necessary to determine involvement of the small bowel.
Appendices
Utilization Guidelines
1. Claims submitted for more than one service per episode of illness will be denied as not medically necessary.
2. Claims for additional tests will be denied as not medically necessary in the absence of supportive documentation.
Sources of Information and Basis for Decision
2. Claims for additional tests will be denied as not medically necessary in the absence of supportive documentation.
- Other Contractors LCDs
- Albert et al, "Diagnosis of small bowel Crohn's disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis", bmjjournals.com; 16 November 2005.
- Appleyard, Glukhovsky and Swain, The New England Journal of Medicine 344:232-233 (Jan.18, 2001)
- Appleyard, et al, Gastroenterology, 119: 1431-1438 (2000)
- Chong et al, Capsule endoscopy vs. push enterscopy and enteroclysis in suspected small-bowel Crohn's disease, GI Endoscopy; vol. 61, no. 2: 2005: 255-263.
- Culliford et al, The value of wireless capsule endoscopy in patients with complicated celiac disease, GI Endoscopy; vol. 65, no. 1: 2005: 55-61.
- Dubcenco et al, Capsule endoscopy findings in patients with established and suspected small-bowel Crohn's disease: correlation with radiologic, endoscopic, and histologic findings, GI Endoscopy; vol. 62, no.4: 2005: 538-544.
- Eisen GM Capsule Endoscopy Indications ASGE Clinical Update Vol. 14, No. 1, July 2006 at www.asge.org/www.askasge.org
- Eliakim, R. et al, Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computerized tomography in patients with suspected Crohn's disease. European Journal of Gastroenterology & Hepatology 2003, Vol 15 No 3
- Fireman, E. et al. Diagnosing small bowel Crohn's disease with wireless capsule endoscopy.
Gut 2003; 52:390-392, (www.gutjnl.com)
- Fleischer, David E.Capsule Endoscopy: The voyage is fantastic-will it change what we do? Gastrointestinal Endoscopy, Volume 56, No. 3, 2002
- Frenette, Catherine T, et al, "Comparison of esophageal capsule endoscopy and esophagogastroduodenoscopy for diagnosis of esophageal varices". World J Gastroenterology 2008 July 28; 14(28): 4480-4485
- Friedman, S. et al, Gastrointestinal Endoscopy Clinics of North America, Vol 14(January 2004), Capsule video endoscopy in Crohn's disease-the European experience.
- Goldfarb et al, "Diagnosing Crohn's Disease: An Economic Analysis Comparing Wireless Capsule Endoscopy with Traditional Diagnostic Procedures", Disease Management, vol. 7, no. 4, 2004, 292-304.
- Herrerias, JM et al, Endoscopy 35: 564-568 (2003), Capsule Endoscopy in Patients with Suspected Crohn's Disease and Negative Endoscopy.
- Keuchel, M. and Hagenmuller, F., Gastrointestinal Endoscopy Clinics of North America, Vol 14 (January 2004), Video capsule endoscopy in the work-up of abdominal pain
- Lewis et al, "A Pooled Analysis to Evaluate Results of Capsule Endoscopy Trials", Endoscopy 2005; 37 (10): 960-965.
- Marmo et al, "Capsule Endoscopy Versus Enteroclysis in the Detection of Small-Bowel Involvement in Crohn's Disease: A Prospective Trial", Clinical Gastroenterology and Hepatology 2005; 3: 772-776.
- Mishkin DS, Chuttani R, Croffie J, et al. ASGE Technology Status Evaluation Report: wireless capsule endoscopy Gastrointest Endosc. 2006 p539-545 www.giejournal.org Volume 63, No. 4: 2006
- Mow, WS et al, Clinical Gastroenterology and Hepatology 1: 31-40 (2004), Initial Experience with Wireless Capsule Enteroscoy in the Diagnosis and Management of Inflammatory Bowel Disease.
- Petroniene et al, "Given Capsule Endoscopy in Celiac Disease: Evaluation of Diagnostic Accuracy and Interoberver Agreement", AJG; 2005; 100: 685-694.
- Volerholzer et al,Small Bowel involvement in Crohn's disease: a prospective comparison of wireless capsule endoscopy and computed tomography enteroclysis, mfjjournals.com, March 1, 2005.
- Sharma Prateek, MD et al. "The diagnostic Accuracy of Esophageal Capsule Endoscopy in Patients with Gastroesophageal Reflux Disease and Barrett's Esophagus: A Blinded, Prospective Study". The American Journal of Gastroenterology, published 04/22/2008
Waye, J.D. Small-Intestinal endoscopy. Endoscopy, 2001 Jan. 33 (1): 24-30.
- The Given® Diagnostic Imaging System M2A® Capsule Endoscopy website@www.givenimaging.com
- Albert et al, "Diagnosis of small bowel Crohn's disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis", bmjjournals.com; 16 November 2005.
- Appleyard, Glukhovsky and Swain, The New England Journal of Medicine 344:232-233 (Jan.18, 2001)
- Appleyard, et al, Gastroenterology, 119: 1431-1438 (2000)
- Chong et al, Capsule endoscopy vs. push enterscopy and enteroclysis in suspected small-bowel Crohn's disease, GI Endoscopy; vol. 61, no. 2: 2005: 255-263.
- Culliford et al, The value of wireless capsule endoscopy in patients with complicated celiac disease, GI Endoscopy; vol. 65, no. 1: 2005: 55-61.
- Dubcenco et al, Capsule endoscopy findings in patients with established and suspected small-bowel Crohn's disease: correlation with radiologic, endoscopic, and histologic findings, GI Endoscopy; vol. 62, no.4: 2005: 538-544.
- Eisen GM Capsule Endoscopy Indications ASGE Clinical Update Vol. 14, No. 1, July 2006 at www.asge.org/www.askasge.org
- Eliakim, R. et al, Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computerized tomography in patients with suspected Crohn's disease. European Journal of Gastroenterology & Hepatology 2003, Vol 15 No 3
- Fireman, E. et al. Diagnosing small bowel Crohn's disease with wireless capsule endoscopy.
Gut 2003; 52:390-392, (www.gutjnl.com)
- Fleischer, David E.Capsule Endoscopy: The voyage is fantastic-will it change what we do? Gastrointestinal Endoscopy, Volume 56, No. 3, 2002
- Frenette, Catherine T, et al, "Comparison of esophageal capsule endoscopy and esophagogastroduodenoscopy for diagnosis of esophageal varices". World J Gastroenterology 2008 July 28; 14(28): 4480-4485
- Friedman, S. et al, Gastrointestinal Endoscopy Clinics of North America, Vol 14(January 2004), Capsule video endoscopy in Crohn's disease-the European experience.
- Goldfarb et al, "Diagnosing Crohn's Disease: An Economic Analysis Comparing Wireless Capsule Endoscopy with Traditional Diagnostic Procedures", Disease Management, vol. 7, no. 4, 2004, 292-304.
- Herrerias, JM et al, Endoscopy 35: 564-568 (2003), Capsule Endoscopy in Patients with Suspected Crohn's Disease and Negative Endoscopy.
- Keuchel, M. and Hagenmuller, F., Gastrointestinal Endoscopy Clinics of North America, Vol 14 (January 2004), Video capsule endoscopy in the work-up of abdominal pain
- Lewis et al, "A Pooled Analysis to Evaluate Results of Capsule Endoscopy Trials", Endoscopy 2005; 37 (10): 960-965.
- Marmo et al, "Capsule Endoscopy Versus Enteroclysis in the Detection of Small-Bowel Involvement in Crohn's Disease: A Prospective Trial", Clinical Gastroenterology and Hepatology 2005; 3: 772-776.
- Mishkin DS, Chuttani R, Croffie J, et al. ASGE Technology Status Evaluation Report: wireless capsule endoscopy Gastrointest Endosc. 2006 p539-545 www.giejournal.org Volume 63, No. 4: 2006
- Mow, WS et al, Clinical Gastroenterology and Hepatology 1: 31-40 (2004), Initial Experience with Wireless Capsule Enteroscoy in the Diagnosis and Management of Inflammatory Bowel Disease.
- Petroniene et al, "Given Capsule Endoscopy in Celiac Disease: Evaluation of Diagnostic Accuracy and Interoberver Agreement", AJG; 2005; 100: 685-694.
- Volerholzer et al,Small Bowel involvement in Crohn's disease: a prospective comparison of wireless capsule endoscopy and computed tomography enteroclysis, mfjjournals.com, March 1, 2005.
- Sharma Prateek, MD et al. "The diagnostic Accuracy of Esophageal Capsule Endoscopy in Patients with Gastroesophageal Reflux Disease and Barrett's Esophagus: A Blinded, Prospective Study". The American Journal of Gastroenterology, published 04/22/2008
Waye, J.D. Small-Intestinal endoscopy. Endoscopy, 2001 Jan. 33 (1): 24-30.
- The Given® Diagnostic Imaging System M2A® Capsule Endoscopy website@www.givenimaging.com
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 05/15/2009
Illinois 05/13/2009
Michigan 05/06/2009
Minnesota 05/21/2009
J5 MAC 06/04/2009
Open LCD meeting 04/15/09
Wisconsin 05/15/2009
Illinois 05/13/2009
Michigan 05/06/2009
Minnesota 05/21/2009
J5 MAC 06/04/2009
Open LCD meeting 04/15/09
Start Date of Comment Period
06/04/2009
End Date of Comment Period
07/20/2009
Start Date of Notice Period
11/01/2009
Revision History Number
X
Revision History Explanation
06/29/2009 Removed contractor 05392 E MO, this is joining with W MO effective 8/1/09
04/03/2009 Approved
04/02/2009 Added as new Draft LCD AB
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
09/08/2009 Sent to approved due to ICD-9 2008-2009 Annual Update.
10/16/2009 release to final.
3/7/2010 - The description for Bill Type Code 73 was changed
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 23 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 72 was changed
8/1/2010 - The description for Bill Type Code 73 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0409 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0520 was changed
8/1/2010 - The description for Revenue code 0521 was changed
8/1/2010 - The description for Revenue code 0522 was changed
8/1/2010 - The description for Revenue code 0523 was changed
8/1/2010 - The description for Revenue code 0524 was changed
8/1/2010 - The description for Revenue code 0525 was changed
8/1/2010 - The description for Revenue code 0526 was changed
8/1/2010 - The description for Revenue code 0527 was changed
8/1/2010 - The description for Revenue code 0528 was changed
8/1/2010 - The description for Revenue code 0529 was changed
8/1/2010 - The description for Revenue code 0750 was changed
8/1/2010 - The description for Revenue code 0929 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0972 was changed
8/1/2010 - The description for Revenue code 0973 was changed
8/1/2010 - The description for Revenue code 0975 was changed
8/1/2010 - The description for Revenue code 0982 was changed
8/1/2010 - The description for Revenue code 0983 was changed
8/1/2010 - The description for Revenue code 0987 was changed
8/1/2010 - The description for Revenue code 0988 was changed
8/1/2010 - Revenue code 0759 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
01/14/2011 Annual review no change in coverage.
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
02/09/2012 Annual review no change in coverage;
04/03/2009 Approved
04/02/2009 Added as new Draft LCD AB
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
09/08/2009 Sent to approved due to ICD-9 2008-2009 Annual Update.
10/16/2009 release to final.
3/7/2010 - The description for Bill Type Code 73 was changed
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 23 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 72 was changed
8/1/2010 - The description for Bill Type Code 73 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0409 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0520 was changed
8/1/2010 - The description for Revenue code 0521 was changed
8/1/2010 - The description for Revenue code 0522 was changed
8/1/2010 - The description for Revenue code 0523 was changed
8/1/2010 - The description for Revenue code 0524 was changed
8/1/2010 - The description for Revenue code 0525 was changed
8/1/2010 - The description for Revenue code 0526 was changed
8/1/2010 - The description for Revenue code 0527 was changed
8/1/2010 - The description for Revenue code 0528 was changed
8/1/2010 - The description for Revenue code 0529 was changed
8/1/2010 - The description for Revenue code 0750 was changed
8/1/2010 - The description for Revenue code 0929 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0972 was changed
8/1/2010 - The description for Revenue code 0973 was changed
8/1/2010 - The description for Revenue code 0975 was changed
8/1/2010 - The description for Revenue code 0982 was changed
8/1/2010 - The description for Revenue code 0983 was changed
8/1/2010 - The description for Revenue code 0987 was changed
8/1/2010 - The description for Revenue code 0988 was changed
8/1/2010 - Revenue code 0759 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
01/14/2011 Annual review no change in coverage.
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
02/09/2012 Annual review no change in coverage;
Reason for Change
Maintenance (annual review with new changes, formatting, etc.)
Related Documents
This LCD has no Related Documents.
LCD Attachments
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Page Last Updated: Thursday, 01-Mar-2012 14:03:41 CST
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