 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, in Towson, Maryland.

Jonathan Rubenstein, MD

Although Medicare is a federal program, the 50 states, along with the District of Columbia and Puerto Rico, are divided into 12 jurisdictions. Medicare then contracts with private companies to administer the program for those jurisdictions. These private contractors are called Medicare Administrative Contractors (MAC) or Carriers. Each MAC has flexibility in policy development for payment protocols if the policies do not violate national Medicare directives. Each MAC is also charged with responsibly guarding the beneficiaries within the Medicare program. The Centers for Medicare & Medicaid Services has an interactive Medicare Jurisdiction Map noting state and MAC with contact information on the Medicare website: https://go.cms.gov/3xXOyg6.

Over the years, Medicare has encouraged the MACs to develop policies based on location with input from physicians in the state working in conjunction with state medical organizations. The system has evolved. It is our understanding that MACs are encouraged to communicate with one another to provide some consistency across jurisdictions as they develop payment policies; however, they are not required to mimic payment policies developed for other jurisdictions. Medicare requires all MACs to adhere to updated processes for developing and releasing payment policy and to participate in supporting a centralized policy location tool; Medicare centrally continues to develop national policies when deemed appropriate.

Under current Medicare protocol, carriers are allowed to develop local coverage determinations (LCDs) based on current medical practice and necessity to provide general coverage guidance for services provided to Medicare beneficiaries. Each LCD must be developed with active stakeholder input and after being issued as a proposed policy with comment period before it is finalized and adopted. The MAC is required to respond to all comments submitted during the designated review period. After consideration of the comments, the MAC can revise and publish the policy.

Coding/billing instructions associated with an LCD are communicated in local coverage articles (LCA) because the LCD is intended to outlast any possible coding changes that may occur each year. A MAC may issue an LCA without a corresponding LCD to provide coding direction for services that may not require a full LCD. LCDs and LCAs can be found on the Medicare Coverage Database and on MAC websites.

On April 17, 2022, a multijurisdictional LCD for Multiplex Nucleic Acid Amplification Test (NAAT) Panels for Infectious Disease Testing was published. This was not adopted for all jurisdictions but rather for the following MACs: Wisconsin Physician Services Insurance Corporation; CGS Administrators, LLC; Noridian Healthcare Services, LLC; and Palmetto GBA.

The LCD followed Medicare protocol, with several national meetings with participation from stakeholders in 48 states and Puerto Rico. Comments on the LCD originally released in 2021 resulted in an amended LCD based on comments from stakeholders participating in meetings and submitted separately during the designated comment period.

Each MAC has also issued an associated LCA with coding instructions and limitations on coverage. All states affected by the LCD and LCA participate in the MolDX program administered by Palmetto GBA. The LCA includes coverage and coding instructions for the use of these greater than 5 tests per specimen (often referred to as PCR testing) for urinary tract infections (UTI) and sexually transmitted infections.

In summary, each laboratory within these jurisdictions that performs NAAT panels for infectious diseases will need to apply for a Z code through the MolDX program. More specifically, each lab will need to apply for a unique Z code for each panel of tests being ordered/performed.

For example, if a urology group has 3 separate test panels for UTIs, the group will be required to obtain its own unique Z code for each test panel. For those groups using a reference lab for such panels, the lab will need to apply for a Z code and request sharing. If a group has multiple lab locations and each lab is performing the same test, only 1 application is required for the entity to which the Clinical Laboratory Improvement Amendments are assigned.

Once the application is submitted, MolDX will perform a technical assessment prior to issuing the Z code. After the technical assessment is completed and the Z code is issued, the lab will receive notification, Z code, and billing instructions. Billing for a panel test is usually cross-walked to a CPT type code and not reported with the Z code issued. The following link will provide additional information on the process: https://bit.ly/3rVAf7U.

It should be noted that within the LCAs for each of the MACs there is a reference—either in the article that became effective April 17, 2022, or in the comments in response to requests from those within the MAC—that there are no FDA-approved UTI panels. Billing for UTI NAAT (PCR) tests will not be allowed until the technical assessment is complete and the Z code is issued, nor will the system allow for retroactive billing of these tests.

The remaining MACs (First Coast Service Options, National Government Services, and Novitas Solutions) do not participate in the MolDX program and Z codes are therefore not required. However, these MACs can implement these LCDs or similar ones if they choose to pursue this in the future. Instead of Z codes for these states, panel tests will likely be reported under Proprietary Laboratory Analyses (PLA) Current Procedural Terminology (CPT) codes. PLA codes can be obtained from CPT and are alphanumeric. Obtaining a PLA code is not as time consuming as standard CPT code applications. PLA codes are issued quarterly by the American Medical Association. PLA codes were designed to allow specific lab test protocols/panels to be assigned a grouped service code for accurate reporting and adjudication. If you practice in a jurisdiction served by one of the MACs that does not participate in the MolDX program and has not issued an LCD, you will not be required to change your current billing practices.

Regardless of one’s location, the response by the MACs to this issue indicates that billing for PCR services has been noted as a potential area for abuse. We have spoken with many practices considering and/or implementing this tool for diagnosis and subsequent treatment of UTIs and other urologic problems. Most groups understand well the requirement, regardless of published billing protocols, that all claims submitted for payment must be medically reasonable and necessary. Number of tests ordered/performed and presenting complaint/condition of the patient must be accurately noted in the medical record. Many practices have also developed clinical guidelines for the appropriate use of PCR testing. As more published peer-reviewed articles address these tests, we would expect Medicare and other payers to adapt payment policy and coding guidance to any new clinical findings.

Send coding and reimbursement questions to Rubenstein and Painter c/o

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Articles

Labs will need to apply for unique Z code for each panel of tests ordered.

LCD addresses NAAT panels for infectious disease testing

Is it appropriate to use 0649T(quantitative magnetic resonance for analysis of tissue composition [eg, fat, iron, water content], including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy [eg, organ, gland, tissue, target structure]

single organ [list separately in addition to code for primary procedure])as an add-on code to multiparametric MRI of the prostate?

Code 0649T was accepted as an “investigational” (category III) code at a Current Procedural Terminology (CPT) meeting last year, using this seemingly proprietary liver imaging test as the justification. The 

 mentions its use specifically with this particular liver scan.

However, the CPT code, as is typical for CPT codes, was written to address the technology more broadly instead of referencing a particular test or service. As published, it does appear to leave the door open to be used in other organs such as the prostate (72197), and there is no list of primary codes that would restrict its use as an add-on for code 72197.

However, neither the American Urological Association nor Physician Reimbursement Systems have been made aware that it could or would be used for the prostate. Radiologists have been reading prostate MRIs using 72197 for around a decade without discussion that another add-on code would be needed or appropriate. We are unaware of the efficacy related to the service or whether the analysis is additional or included relative to code 72197.

Codes 0648T and 0649T were designed to report QuantitativeMultiparametric MR for analysis of tissue composition. They were designed to be used in any organ or tissue in the body. However, the key word is 

, meaning an actual quantitative analysis must be performed. That requires actual reporting of quantitative values related to tissue properties, not just a qualitative assessment. There are many examples of quantitative sequences being qualitatively interpreted and that would not meet the threshold of coding 0648T or 0649T. Currently, the most common use for these new codes is in the liver, but research is ongoing for their use in other organs. In our experience thus far, this type of quantitative assessment and reporting is not typically being performed in conjunction with prostate MRI.

 at this time appears to be restricted to the liver scan. If the service is indeed justified and supported, we would recommend checking with the payer prior to submitting code 0649T.

1. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of Hospital Standard Charges; Radiation Oncology Model. 

. 2021;86(218):84. Accessed March 18, 2022. https://www.federalregister.gov/documents/2021/11/16/2021-24011/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o

“If the service is indeed justified and supported, we would recommend checking with the payer prior to submitting code 0649T,” write Jonathan Rubenstein, MD, and Mark Painter.

Is it appropriate to use 0649T as an add-on code to multiparametric MRI of the prostate?

My provider performed a laparoscopic radical nephrectomy (90-day global procedure) on a patient with a renal mass worrisome for kidney cancer. I was told not to use a “kidney cancer” diagnosis until cancer was proven, so I used a “renal mass” ICD-10 code. The final pathology report confirmed kidney cancer. My provider wants to bill for the post-op visits within 90 days saying billable because the patient now has a diagnosis of cancer that they did not have before the surgery. Can we bill those visits?

The short answer is no. But it may be best to explain why Let’s start with the diagnosis code portion. The 

International Classification of Diseases, Tenth Revision, Clinical Modification

) guidelines instruct the clinician to choose a diagnosis code that accurately describes a patient’s clinical condition or reason for visit. Additionally, the guidelines instruct the coder supporting the clinician to check the appropriate code selection with the clinician when there is a question. In short, the clinician has the final say regarding which 

It is likely there are clinicians who would argue that based upon imaging alone, they are comfortable making a diagnosis of cancer without a biopsy or tissue diagnosis, especially with more modern imaging. However, we believe that it remains best practice to only use a cancer diagnosis code in patients with pathologic tissue confirmation with rare exceptions (such as with cancer recurrence or metastasis and those who need treatment and tissue cannot be obtained). In addition to the medical implications of a cancer diagnosis, many such diagnoses will affect patient insurability and potential employment. From a coding perspective, diagnoses assigned prior to confirmation may result in the bundling of care that should be separately payable. That being said, at times a clinician needs to use their best clinical judgment when caring for an individual patient, as some patients may not be eligible for certain therapies without the corresponding diagnosis codes being chosen. However, in the case of the renal mass mentioned above, most providers will use a “renal mass” diagnosis code instead of a “kidney cancer” code.

Now, let’s get to the question about whether visits within 90 days after laparoscopic radical nephrectomy are billable if a patient now has a definitive diagnosis of kidney cancer. The global surgical package is set up in a way such that payment has already been made to include all the necessary services normally furnished by a surgeon before, during, and after a procedure. That means that all hospital and outpatient visit that occur within that global period have been paid, unless an exception exists. According to Medicare, services such as evaluation and management (E/M) visits that are not included in the global payment package and are separately payable within a global period include:

1. Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

2. Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.

In this particular case, the intent of the surgery was for the treatment of a known or suspected kidney cancer, whether or not a kidney cancer diagnoses code was used or was confirmed before the procedure. Had the physician not suspected that the patient had cancer, the patient would likely not have undergone the nephrectomy. A computer may require and allow for an E/M code to be reported with a different diagnosis than used for the surgery and modifier –24 (Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period), which states that the “physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.” However, the definition of the modifier is not specific to the diagnosis code but instead focuses on “reason(s) unrelated to the original procedure,” nor is the Medicare rule limited to a specific diagnosis—“visits unrelated to the diagnosis for which the original surgical procedure is performed

Therefore, billing for the visits based solely on a change in diagnostic code is not appropriate, as noted in point 1 above.The visits are clearly related to the reason(s) for which the surgical service was performed, regardless of the 

 code reported for the surgical service. On the other hand, the second point above would warrant additional consideration.

Chemotherapy care provided for the systemic treatment of cancer is not related to the recovery from surgery. Instead, it is targeted to treatment of the underlying disease and is an added course of treatment not considered a part of normal recovery from surgery. Under this exception, the services related to the treatment for kidney cancer are payable.

The visits for planning and follow-up during the global period are not as clear cut. In reviewing multiple charts, it is common for a physician to discuss with the patient, prior to laparoscopic radical nephrectomy, the potential for kidney cancer and the need for further treatment after surgery, including chemotherapy. As this discussion is common for surgery, it is harder to support the position that this planning is not a normal part of the recovery from surgery. If there is no suspicion of cancer and the laparoscopic partial nephrectomy is performed with a discovery of cancer during or after surgery, the argument that the cancer treatment planning and follow-up for cancer is not a part of normal recovery is supported. Even with that differentiation, we have to remember that relative value units and rules are developed not for the individual case but instead for the average case.

In summary, charging for visits during the postoperative period for planning and follow-up of cancer will depend on documentation and payer processing. In general, similar to the discussion of stone prevention during the postoperative period of an extracorporeal shock wave lithotripsy, payment may be warranted in some cases but may be difficult to obtain.

Pathologic tissue confirmation is usually the best practice.

Can one choose a cancer diagnosis code without tissue?

When billing for an evaluation/management (E/M) visit, a patient has a left nonobstructed kidney stone (N20.0) and a right hydronephrosis ureteral stone (N13.2). In 

 under N20, it shows EXCLUDED 1: that with hydronephrosis (N13.2).

Can I bill N20.0 and N13.2 on the same Current Procedural Terminology line (E/M line)? I have run into denied claims in the past, and I am not sure if I should bill only 1 

We are seeing an increase in payer edits that are referencing 

 guidelines such as “Excludes 1” notes. As you mentioned, code N20.

The note applies to all N20 codes, including N20.0, N20.1, and N20.2. The 

 guidelines state that if code(s) notes include an Excludes 1 list, the 

 codes listed under the note should not be reported in conjunction with the codes for which the note is listed. Interestingly, if you look under code N13.2, you will not see a reciprocal reference. In short, it is not correct coding to list code N20.0 and N13.2 for the same patient encounter.

It is correct coding to list a single diagnosis if the code accurately describes the patient’s condition. Therefore, you should not receive a denial if only 1 

 code is listed for the claim. If the patient has other conditions that are not listed in the notes as “Excludes 1” or “Includes codes,” it is appropriate to list more than 1 