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Sphenopalatine Ganglion Block with Medication Delivery
One of our physicians is using a device to deliver medication through the nose when a sphenopalatine ganglion block is performed under fluoroscopic guidance for patients with migraine headaches. Can we report 64505 for this service? If not, what is the best code to report?
Question:
One of our physicians is using a device to deliver medication through the nose when a sphenopalatine ganglion block is performed under fluoroscopic guidance for patients with migraine headaches. Can we report 64505 for this service? If not, what is the best code to report?
Answer:
There is no specific CPT code that accurately describes the service. The code set includes CPT code 64505, which describes the injection of the sphenopalatine ganglion; however, it is inappropriate to report this code since an injection is not performed. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported.
Another variation on blocking the sphenopalatine ganglion is using a Q-tip to apply anesthetic topically through the nose. There is no specific CPT code for this procedure, which is best reported as part of the E/M service.
*This response is based on the best information available as of 10/17/24.
Collagen Dressings
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Question:
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Answer:
Thank you for your inquiry. Several factors have to be considered.
First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.
Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.
Per Medicare Claims Processing Manual, Chapter 12, Section 40.1
o Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket. Depending on medical necessity, the dressings may or may not be covered under a home health benefit.
Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.
Per Medicare LCD L33831:
Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)
A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal. They can stay in place for up to 7 days. Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.
To justify payment for DMEPOS items, suppliers must meet the following requirements:
Standard Written Order Criteria (SWO)
Medical Record Information (including continued need/use if applicable)
Correct Coding
Proof of Delivery
Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.
Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.
LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831
As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).
*This response is based on the best information available as of 10/17/24.
New Versus Established in the Office
We have one Facial Plastic surgeon in our practice with five otolaryngologists. We have a patient who sees our facial plastic surgeon sees a patient for the first time. The patient is established to our practice and has been seen in the past three years. Is the patient considered “new” the first time the Facial Plastic surgeon sees the patient?
Question:
We are an otolaryngology practice, and we added a facial plastic surgeon to our group. If he sees one of our established patients for the first time in the office, would that be a new or established patient for the plastic surgeon? He does not share the same taxonomy or specialty code with our Otolaryngologists and is credentialed as specialty code 24.
Answer:
This is a great question. Since the Facial Plastic surgeon is credentialed as specialty 24 and Otolaryngology is credentialed as specialty 04, the patient would be considered a new patient for the plastic surgeon. Understanding the coding rules for new versus established patients in the office or outpatient setting is important.
A new patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
An established patient has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the same specialty and subspecialty who belongs to the same group practice within the past three years.
*This response is based on the best information available as of 10/17/24.
Collagen Dressings
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Question:
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Answer:
Thank you for your inquiry. Several factors have to be considered.
First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.
Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.
Per Medicare Claims Processing Manual, Chapter 12, Section 40.1
o Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket. Depending on medical necessity, the dressings may or may not be covered under a home health benefit.
Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.
Per Medicare LCD L33831:
Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)
A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal. They can stay in place for up to 7 days. Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.
To justify payment for DMEPOS items, suppliers must meet the following requirements:
Standard Written Order Criteria (SWO)
Medical Record Information (including continued need/use if applicable)
Correct Coding
Proof of Delivery
Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.
Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.
LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831
As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).
*This response is based on the best information available as of 10/17/24.
Collagen Dressings
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Question:
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Answer:
Thank you for your inquiry. Several factors have to be considered.
First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.
Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.
Per Medicare Claims Processing Manual, Chapter 12, Section 40.1
o Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket. Depending on medical necessity, the dressings may or may not be covered under a home health benefit.
Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.
Per Medicare LCD L33831:
Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)
A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal. They can stay in place for up to 7 days. Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.
To justify payment for DMEPOS items, suppliers must meet the following requirements:
Standard Written Order Criteria (SWO)
Medical Record Information (including continued need/use if applicable)
Correct Coding
Proof of Delivery
Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.
Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.
LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831
As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).
*This response is based on the best information available as of 10/17/24.
Collagen Dressings
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Question:
Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?
Answer:
Thank you for your inquiry. Several factors have to be considered.
First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.
Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.
Per Medicare Claims Processing Manual, Chapter 12, Section 40.1
o Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket. Depending on medical necessity, the dressings may or may not be covered under a home health benefit.
Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.
Per Medicare LCD L33831:
Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)
A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal. They can stay in place for up to 7 days. Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.
To justify payment for DMEPOS items, suppliers must meet the following requirements:
Standard Written Order Criteria (SWO)
Medical Record Information (including continued need/use if applicable)
Correct Coding
Proof of Delivery
Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.
Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.
LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831
As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).
*This response is based on the best information available as of 10/17/24.
